hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|[state],"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Jeff Davis Hospital,2/29/2024,2.0.0,Jeff Davis Hospital,"163 S. Tallahassee St. Hazlehurst, GA 31539-2921",580903829|GA,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AMERIGROUP|MEDICAID|negotiated_dollar,standard_charge|AMERIGROUP|MEDICAID|negotiated_percentage,standard_charge|AMERIGROUP|MEDICAID|negotiated_algorithm,estimated_amount|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|MEDICAID|methodology,additional_payer_notes|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|PEACHSTATE_FOR_KIDS|negotiated_dollar,standard_charge|AMERIGROUP|PEACHSTATE_FOR_KIDS|negotiated_percentage,standard_charge|AMERIGROUP|PEACHSTATE_FOR_KIDS|negotiated_algorithm,estimated_amount|AMERIGROUP|PEACHSTATE_FOR_KIDS,standard_charge|AMERIGROUP|PEACHSTATE_FOR_KIDS|methodology,additional_payer_notes|AMERIGROUP|PEACHSTATE_FOR_KIDS,standard_charge|BCBS|HMO|negotiated_dollar,standard_charge|BCBS|HMO|negotiated_percentage,standard_charge|BCBS|HMO|negotiated_algorithm,estimated_amount|BCBS|HMO,standard_charge|BCBS|HMO|methodology,additional_payer_notes|BCBS|HMO,standard_charge|BCBS|POS|negotiated_dollar,standard_charge|BCBS|POS|negotiated_percentage,standard_charge|BCBS|POS|negotiated_algorithm,estimated_amount|BCBS|POS,standard_charge|BCBS|POS|methodology,additional_payer_notes|BCBS|POS,standard_charge|BCBS|PPO|negotiated_dollar,standard_charge|BCBS|PPO|negotiated_percentage,standard_charge|BCBS|PPO|negotiated_algorithm,estimated_amount|BCBS|PPO,standard_charge|BCBS|PPO|methodology,additional_payer_notes|BCBS|PPO,standard_charge|BCBS|MEDICARE_HMO|negotiated_dollar,standard_charge|BCBS|MEDICARE_HMO|negotiated_percentage,standard_charge|BCBS|MEDICARE_HMO|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_HMO,standard_charge|BCBS|MEDICARE_HMO|methodology,additional_payer_notes|BCBS|MEDICARE_HMO,standard_charge|BCBS|MEDICARE_INDEMNITY|negotiated_dollar,standard_charge|BCBS|MEDICARE_INDEMNITY|negotiated_percentage,standard_charge|BCBS|MEDICARE_INDEMNITY|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_INDEMNITY,standard_charge|BCBS|MEDICARE_INDEMNITY|methodology,additional_payer_notes|BCBS|MEDICARE_INDEMNITY,standard_charge|BCBS|MEDICARE_OPEN_ACCESS|negotiated_dollar,standard_charge|BCBS|MEDICARE_OPEN_ACCESS|negotiated_percentage,standard_charge|BCBS|MEDICARE_OPEN_ACCESS|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_OPEN_ACCESS,standard_charge|BCBS|MEDICARE_OPEN_ACCESS|methodology,additional_payer_notes|BCBS|MEDICARE_OPEN_ACCESS,standard_charge|BCBS|MEDICARE_PAR|negotiated_dollar,standard_charge|BCBS|MEDICARE_PAR|negotiated_percentage,standard_charge|BCBS|MEDICARE_PAR|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_PAR,standard_charge|BCBS|MEDICARE_PAR|methodology,additional_payer_notes|BCBS|MEDICARE_PAR,standard_charge|BCBS|MEDICARE_POS|negotiated_dollar,standard_charge|BCBS|MEDICARE_POS|negotiated_percentage,standard_charge|BCBS|MEDICARE_POS|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_POS,standard_charge|BCBS|MEDICARE_POS|methodology,additional_payer_notes|BCBS|MEDICARE_POS,standard_charge|BCBS|MEDICARE_PPO|negotiated_dollar,standard_charge|BCBS|MEDICARE_PPO|negotiated_percentage,standard_charge|BCBS|MEDICARE_PPO|negotiated_algorithm,estimated_amount|BCBS|MEDICARE_PPO,standard_charge|BCBS|MEDICARE_PPO|methodology,additional_payer_notes|BCBS|MEDICARE_PPO,standard_charge|BEECH_STREET|COMMERCIAL|negotiated_dollar,standard_charge|BEECH_STREET|COMMERCIAL|negotiated_percentage,standard_charge|BEECH_STREET|COMMERCIAL|negotiated_algorithm,estimated_amount|BEECH_STREET|COMMERCIAL,standard_charge|BEECH_STREET|COMMERCIAL|methodology,additional_payer_notes|BEECH_STREET|COMMERCIAL,standard_charge|CARE_IMPROVEMENT_PLUS|COMMERCIAL|negotiated_dollar,standard_charge|CARE_IMPROVEMENT_PLUS|COMMERCIAL|negotiated_percentage,standard_charge|CARE_IMPROVEMENT_PLUS|COMMERCIAL|negotiated_algorithm,estimated_amount|CARE_IMPROVEMENT_PLUS|COMMERCIAL,standard_charge|CARE_IMPROVEMENT_PLUS|COMMERCIAL|methodology,additional_payer_notes|CARE_IMPROVEMENT_PLUS|COMMERCIAL,standard_charge|CARESOURCE|COMMERCIAL|negotiated_dollar,standard_charge|CARESOURCE|COMMERCIAL|negotiated_percentage,standard_charge|CARESOURCE|COMMERCIAL|negotiated_algorithm,estimated_amount|CARESOURCE|COMMERCIAL,standard_charge|CARESOURCE|COMMERCIAL|methodology,additional_payer_notes|CARESOURCE|COMMERCIAL,standard_charge|CHOICECARE|COMMERCIAL|negotiated_dollar,standard_charge|CHOICECARE|COMMERCIAL|negotiated_percentage,standard_charge|CHOICECARE|COMMERCIAL|negotiated_algorithm,estimated_amount|CHOICECARE|COMMERCIAL,standard_charge|CHOICECARE|COMMERCIAL|methodology,additional_payer_notes|CHOICECARE|COMMERCIAL,standard_charge|CHOICECARE|MEDICARE_PPO|negotiated_dollar,standard_charge|CHOICECARE|MEDICARE_PPO|negotiated_percentage,standard_charge|CHOICECARE|MEDICARE_PPO|negotiated_algorithm,estimated_amount|CHOICECARE|MEDICARE_PPO,standard_charge|CHOICECARE|MEDICARE_PPO|methodology,additional_payer_notes|CHOICECARE|MEDICARE_PPO,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|COMMUNITY_CARE_NETWORK|COMMERCIAL|negotiated_dollar,standard_charge|COMMUNITY_CARE_NETWORK|COMMERCIAL|negotiated_percentage,standard_charge|COMMUNITY_CARE_NETWORK|COMMERCIAL|negotiated_algorithm,estimated_amount|COMMUNITY_CARE_NETWORK|COMMERCIAL,standard_charge|COMMUNITY_CARE_NETWORK|COMMERCIAL|methodology,additional_payer_notes|COMMUNITY_CARE_NETWORK|COMMERCIAL,standard_charge|COVENTRY|HMO|negotiated_dollar,standard_charge|COVENTRY|HMO|negotiated_percentage,standard_charge|COVENTRY|HMO|negotiated_algorithm,estimated_amount|COVENTRY|HMO,standard_charge|COVENTRY|HMO|methodology,additional_payer_notes|COVENTRY|HMO,standard_charge|COVENTRY|POS|negotiated_dollar,standard_charge|COVENTRY|POS|negotiated_percentage,standard_charge|COVENTRY|POS|negotiated_algorithm,estimated_amount|COVENTRY|POS,standard_charge|COVENTRY|POS|methodology,additional_payer_notes|COVENTRY|POS,standard_charge|COVENTRY|PPO|negotiated_dollar,standard_charge|COVENTRY|PPO|negotiated_percentage,standard_charge|COVENTRY|PPO|negotiated_algorithm,estimated_amount|COVENTRY|PPO,standard_charge|COVENTRY|PPO|methodology,additional_payer_notes|COVENTRY|PPO,standard_charge|COVENTRY|MEDICARE|negotiated_dollar,standard_charge|COVENTRY|MEDICARE|negotiated_percentage,standard_charge|COVENTRY|MEDICARE|negotiated_algorithm,estimated_amount|COVENTRY|MEDICARE,standard_charge|COVENTRY|MEDICARE|methodology,additional_payer_notes|COVENTRY|MEDICARE,standard_charge|GEORGIA_HEALTH_NETWORK|COMMERCIAL|negotiated_dollar,standard_charge|GEORGIA_HEALTH_NETWORK|COMMERCIAL|negotiated_percentage,standard_charge|GEORGIA_HEALTH_NETWORK|COMMERCIAL|negotiated_algorithm,estimated_amount|GEORGIA_HEALTH_NETWORK|COMMERCIAL,standard_charge|GEORGIA_HEALTH_NETWORK|COMMERCIAL|methodology,additional_payer_notes|GEORGIA_HEALTH_NETWORK|COMMERCIAL,standard_charge|HUMANA|EPO|negotiated_dollar,standard_charge|HUMANA|EPO|negotiated_percentage,standard_charge|HUMANA|EPO|negotiated_algorithm,estimated_amount|HUMANA|EPO,standard_charge|HUMANA|EPO|methodology,additional_payer_notes|HUMANA|EPO,standard_charge|HUMANA|HMO|negotiated_dollar,standard_charge|HUMANA|HMO|negotiated_percentage,standard_charge|HUMANA|HMO|negotiated_algorithm,estimated_amount|HUMANA|HMO,standard_charge|HUMANA|HMO|methodology,additional_payer_notes|HUMANA|HMO,standard_charge|HUMANA|HMO|negotiated_dollar,standard_charge|HUMANA|POS|negotiated_percentage,standard_charge|HUMANA|POS|negotiated_algorithm,estimated_amount|HUMANA|POS,standard_charge|HUMANA|POS|methodology,additional_payer_notes|HUMANA|POS,standard_charge|HUMANA|PPO|negotiated_dollar,standard_charge|HUMANA|PPO|negotiated_percentage,standard_charge|HUMANA|PPO|negotiated_algorithm,estimated_amount|HUMANA|PPO,standard_charge|HUMANA|PPO|methodology,additional_payer_notes|HUMANA|PPO,standard_charge|HUMANA|MEDICAID|negotiated_dollar,standard_charge|HUMANA|MEDICAID|negotiated_percentage,standard_charge|HUMANA|MEDICAID|negotiated_algorithm,estimated_amount|HUMANA|MEDICAID,standard_charge|HUMANA|MEDICAID|methodology,additional_payer_notes|HUMANA|MEDICAID,standard_charge|HUMANA|MEDICARE_HMO|negotiated_dollar,standard_charge|HUMANA|MEDICARE_HMO|negotiated_percentage,standard_charge|HUMANA|MEDICARE_HMO|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_HMO,standard_charge|HUMANA|MEDICARE_HMO|methodology,additional_payer_notes|HUMANA|MEDICARE_HMO,standard_charge|HUMANA|MEDICARE_PFFS|negotiated_dollar,standard_charge|HUMANA|MEDICARE_PFFS|negotiated_percentage,standard_charge|HUMANA|MEDICARE_PFFS|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_PFFS,standard_charge|HUMANA|MEDICARE_PFFS|methodology,additional_payer_notes|HUMANA|MEDICARE_PFFS,standard_charge|HUMANA|MEDICARE_POS|negotiated_dollar,standard_charge|HUMANA|MEDICARE_POS|negotiated_percentage,standard_charge|HUMANA|MEDICARE_POS|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_POS,standard_charge|HUMANA|MEDICARE_POS|methodology,additional_payer_notes|HUMANA|MEDICARE_POS,standard_charge|HUMANA|MEDICARE_POS|negotiated_dollar,standard_charge|HUMANA|MEDICARE_PPO|negotiated_percentage,standard_charge|HUMANA|MEDICARE_PPO|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_PPO,standard_charge|HUMANA|MEDICARE_PPO|methodology,additional_payer_notes|HUMANA|MEDICARE_PPO,standard_charge|INDUSTRY_BUYING_GROUP|COMMERCIAL|negotiated_dollar,standard_charge|INDUSTRY_BUYING_GROUP|COMMERCIAL|negotiated_percentage,standard_charge|INDUSTRY_BUYING_GROUP|COMMERCIAL|negotiated_algorithm,estimated_amount|INDUSTRY_BUYING_GROUP|COMMERCIAL,standard_charge|INDUSTRY_BUYING_GROUP|COMMERCIAL|methodology,additional_payer_notes|INDUSTRY_BUYING_GROUP|COMMERCIAL,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL|negotiated_dollar,standard_charge|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL|negotiated_percentage,standard_charge|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL|negotiated_algorithm,estimated_amount|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL,standard_charge|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL|methodology,additional_payer_notes|MEMORIAL_HEALTH_PARTNERS|COMMERCIAL,standard_charge|MOLINA|MEDICAID|negotiated_dollar,standard_charge|MOLINA|MEDICAID|negotiated_percentage,standard_charge|MOLINA|MEDICAID|negotiated_algorithm,estimated_amount|MOLINA|MEDICAID,standard_charge|MOLINA|MEDICAID|methodology,additional_payer_notes|MOLINA|MEDICAID,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_dollar,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_percentage,standard_charge|MULTIPLAN|COMMERCIAL|negotiated_algorithm,estimated_amount|MULTIPLAN|COMMERCIAL,standard_charge|MULTIPLAN|COMMERCIAL|methodology,additional_payer_notes|MULTIPLAN|COMMERCIAL,standard_charge|NOVANET|COMMERCIAL|negotiated_dollar,standard_charge|NOVANET|COMMERCIAL|negotiated_percentage,standard_charge|NOVANET|COMMERCIAL|negotiated_algorithm,estimated_amount|NOVANET|COMMERCIAL,standard_charge|NOVANET|COMMERCIAL|methodology,additional_payer_notes|NOVANET|COMMERCIAL,standard_charge|ONE_HEALTH_PLAN|PPO|negotiated_dollar,standard_charge|ONE_HEALTH_PLAN|PPO|negotiated_percentage,standard_charge|ONE_HEALTH_PLAN|PPO|negotiated_algorithm,estimated_amount|ONE_HEALTH_PLAN|PPO,standard_charge|ONE_HEALTH_PLAN|PPO|methodology,additional_payer_notes|ONE_HEALTH_PLAN|PPO,standard_charge|PEACH_STATE_HEALTH_PLAN|HMO|negotiated_dollar,standard_charge|PEACH_STATE_HEALTH_PLAN|HMO|negotiated_percentage,standard_charge|PEACH_STATE_HEALTH_PLAN|HMO|negotiated_algorithm,estimated_amount|PEACH_STATE_HEALTH_PLAN|HMO,standard_charge|PEACH_STATE_HEALTH_PLAN|HMO|methodology,additional_payer_notes|PEACH_STATE_HEALTH_PLAN|HMO,standard_charge|PEN|COMMERCIAL|negotiated_dollar,standard_charge|PEN|COMMERCIAL|negotiated_percentage,standard_charge|PEN|COMMERCIAL|negotiated_algorithm,estimated_amount|PEN|COMMERCIAL,standard_charge|PEN|COMMERCIAL|methodology,additional_payer_notes|PEN|COMMERCIAL,standard_charge|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO|negotiated_dollar,standard_charge|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO|negotiated_percentage,standard_charge|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO|negotiated_algorithm,estimated_amount|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO,standard_charge|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO|methodology,additional_payer_notes|PRINCIPAL_HEALTH_CARE_OF_GEORGIA|PPO,standard_charge|THREE_RIVERS_PROVIDER_NETWORK|PPO|negotiated_dollar,standard_charge|THREE_RIVERS_PROVIDER_NETWORK|PPO|negotiated_percentage,standard_charge|THREE_RIVERS_PROVIDER_NETWORK|PPO|negotiated_algorithm,estimated_amount|THREE_RIVERS_PROVIDER_NETWORK|PPO,standard_charge|THREE_RIVERS_PROVIDER_NETWORK|PPO|methodology,additional_payer_notes|THREE_RIVERS_PROVIDER_NETWORK|PPO,standard_charge|TRICARE|COMMERCIAL|negotiated_dollar,standard_charge|TRICARE|COMMERCIAL|negotiated_percentage,standard_charge|TRICARE|COMMERCIAL|negotiated_algorithm,estimated_amount|TRICARE|COMMERCIAL,standard_charge|TRICARE|COMMERCIAL|methodology,additional_payer_notes|TRICARE|COMMERCIAL,standard_charge|UHC|HMO|negotiated_dollar,standard_charge|UHC|HMO|negotiated_percentage,standard_charge|UHC|HMO|negotiated_algorithm,estimated_amount|UHC|HMO,standard_charge|UHC|HMO|methodology,additional_payer_notes|UHC|HMO,standard_charge|UHC|INDEMNITY|negotiated_dollar,standard_charge|UHC|INDEMNITY|negotiated_percentage,standard_charge|UHC|INDEMNITY|negotiated_algorithm,estimated_amount|UHC|INDEMNITY,standard_charge|UHC|INDEMNITY|methodology,additional_payer_notes|UHC|INDEMNITY,standard_charge|UHC|PPO|negotiated_dollar,standard_charge|UHC|PPO|negotiated_percentage,standard_charge|UHC|PPO|negotiated_algorithm,estimated_amount|UHC|PPO,standard_charge|UHC|PPO|methodology,additional_payer_notes|UHC|PPO,standard_charge|UHC|MEDICAID|negotiated_dollar,standard_charge|UHC|MEDICAID|negotiated_percentage,standard_charge|UHC|MEDICAID|negotiated_algorithm,estimated_amount|UHC|MEDICAID,standard_charge|UHC|MEDICAID|methodology,additional_payer_notes|UHC|MEDICAID,standard_charge|USA_MANAGED_CARE|PPO|negotiated_dollar,standard_charge|USA_MANAGED_CARE|PPO|negotiated_percentage,standard_charge|USA_MANAGED_CARE|PPO|negotiated_algorithm,estimated_amount|USA_MANAGED_CARE|PPO,standard_charge|USA_MANAGED_CARE|PPO|methodology,additional_payer_notes|USA_MANAGED_CARE|PPO,standard_charge|WELLCARE|COMMERCIAL|negotiated_dollar,standard_charge|WELLCARE|COMMERCIAL|negotiated_percentage,standard_charge|WELLCARE|COMMERCIAL|negotiated_algorithm,estimated_amount|WELLCARE|COMMERCIAL,standard_charge|WELLCARE|COMMERCIAL|methodology,additional_payer_notes|WELLCARE|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
70498: CT Angio Neck AddOn,1167879,CDM,351,RC,70498,HCPCS,outpatient,,,"$4,515.00 ","$1,580.25 ",,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,580.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,476.55 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$880.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,399.65 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,063.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,289.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,198.95 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$880.43 ,"$4,289.25 ",
74174: CT Angio Abdomen and Pelvis AddOn,2424686,CDM,352,RC,74174,HCPCS,outpatient,,,"$2,551.00 ",$892.85 ,,"$1,367.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,367.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$892.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,785.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,785.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,964.27 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$497.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$790.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,295.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$512.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,423.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,372.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$512.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$497.45 ,"$2,423.45 ",
74176: CT Abdomen and Pelvis w/o Contrast AddOn,28409,CDM,352,RC,74176,HCPCS,outpatient,,,"$6,168.43 ","$2,158.95 ",,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,158.95 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,749.69 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,931.33 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,202.84 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,912.21 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,551.59 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,860.01 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,736.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,202.84 ","$5,860.01 ",
74177: CT Abdomen and Pelvis w/ Contrast AddOn,28410,CDM,352,RC,74177,HCPCS,outpatient,,,"$8,297.63 ","$2,904.17 ",,"$4,447.53 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,447.53 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,638.10 ",80,,,percent of total billed charges,80% of total billed charges,"$2,623.71 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,904.17 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,638.10 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,808.34 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,808.34 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,389.18 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,650.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,597.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.04 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,572.27 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$7,467.87 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,666.16 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,882.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,638.10 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,650.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,716.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,223.22 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,666.16 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,052.99 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,650.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,618.04 ","$7,882.75 ",
74178: CT Abdomen and Pelvis w/ + w/o Contrast AddOn,28411,CDM,352,RC,74178,HCPCS,outpatient,,,"$8,929.66 ","$3,125.38 ",,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,125.38 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,875.84 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,795.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,741.28 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,768.19 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$8,036.69 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,483.18 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,304.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,741.28 ","$8,483.18 ",
76802: US OB <14 Weeks Addl Fetus AddOn,28077,CDM,320,RC,76802,HCPCS,outpatient,,,$443.00 ,$155.05 ,,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$155.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$341.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$137.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$398.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$420.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.39 ,$420.85 ,
77063 Mammo Screening Tomo Bilat: AddOn,10822090,CDM,403,RC,77063,HCPCS,outpatient,,,$30.49 ,$10.67 ,,$16.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.87 ,75,,,percent of total billed charges,75% of total billed charges,$22.87 ,75,,,percent of total billed charges,75% of total billed charges,$22.87 ,75,,,percent of total billed charges,75% of total billed charges,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.39 ,80,,,percent of total billed charges,80% of total billed charges,$9.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$27.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.97 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.95 ,$28.97 ,
Blood Admin Fee,17001,CDM,391,RC,36430,HCPCS,outpatient,,,$407.75 ,$142.71 ,,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$142.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$313.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$127.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$126.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$366.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$387.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$379.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.51 ,$387.36 ,
Cardiac Profile Addon 1,82553Addon,CDM,301,RC,82553,HCPCS,outpatient,,,$76.51 ,$26.78 ,,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$61.21 ,80,,,percent of total billed charges,80% of total billed charges,$24.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.25 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.55 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.55 ,$72.68 ,
Cardiac Profile addon 2,82550Addon,CDM,301,RC,82550,HCPCS,outpatient,,,$45.76 ,$16.02 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.61 ,80,,,percent of total billed charges,80% of total billed charges,$14.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.51 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$43.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.35 ,$43.47 ,
Electrocardiogram 12 Lead Interpretation addon,93000addon,CDM,730,RC,93000,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
Hemoglobin Addon,151171,CDM,305,RC,85018,HCPCS,outpatient,,,$15.73 ,$5.51 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.58 ,80,,,percent of total billed charges,80% of total billed charges,$4.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$14.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$14.94 ,
JDHS Collection Supply Charge,16138,CDM,270,RC,,HCPCS,outpatient,,,$15.00 ,$5.25 ,,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.93 ,$14.25 ,
MG Mammo Diagnostic Bilateral w/ Tomo,203117,CDM,401,RC,77062,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
MG Mammo Diagnostic Left w/ Tomo,203118,CDM,401,RC,77061,HCPCS,outpatient,,,$425.00 ,$148.75 ,,$227.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$340.00 ,80,,,percent of total billed charges,80% of total billed charges,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$148.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$297.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$327.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$131.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$382.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$403.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$395.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.88 ,$403.75 ,
MG Mammo Diagnostic Right w/ Tomo,203119,CDM,401,RC,77061,HCPCS,outpatient,,,$425.00 ,$148.75 ,,$227.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$318.75 ,75,,,percent of total billed charges,75% of total billed charges,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$340.00 ,80,,,percent of total billed charges,80% of total billed charges,$134.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$148.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$297.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$327.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$131.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$382.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$403.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$395.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.88 ,$403.75 ,
MG Mammo Digital Screening Bilateral,8420269,CDM,403,RC,77063,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Protein/Creatinine Ratio Urine addon,15819,CDM,300,RC,82570,HCPCS,outpatient,,,$63.23 ,$22.13 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$50.58 ,80,,,percent of total billed charges,80% of total billed charges,$19.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$60.07 ,
Smoking Cessation addon,20357,CDM,942,RC,99406,HCPCS,outpatient,,,$93.00 ,$32.55 ,,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.14 ,$88.35 ,
"10005 Fine needle aspiration biopsy, including ultrasound guidance",10005,CDM,361,RC,10005,HCPCS,outpatient,,,$251.00 ,$87.85 ,,$134.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$188.25 ,75,,,percent of total billed charges,75% of total billed charges,$188.25 ,75,,,percent of total billed charges,75% of total billed charges,$188.25 ,75,,,percent of total billed charges,75% of total billed charges,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.80 ,80,,,percent of total billed charges,80% of total billed charges,$79.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$193.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$188.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$188.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$188.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.95 ,$238.45 ,
10120  REMOVE FOREIGN BODY,10120,CDM,361,RC,10120,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
11011 Debridement Open Fx/Dislocation; to Muscle,11011,CDM,361,RC,11011,HCPCS,outpatient,,,"$1,003.00 ",$351.05 ,,$537.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$537.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$752.25 ,75,,,percent of total billed charges,75% of total billed charges,$752.25 ,75,,,percent of total billed charges,75% of total billed charges,$752.25 ,75,,,percent of total billed charges,75% of total billed charges,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.40 ,80,,,percent of total billed charges,80% of total billed charges,$317.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$351.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$802.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$702.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$772.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$310.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$902.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$201.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$199.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$932.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$752.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$752.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$752.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$201.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$852.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.59 ,$952.85 ,
11102 Biopsy of Skin,111021,CDM,361,RC,111021,HCPCS,outpatient,,,$180.58 ,$63.20 ,,$96.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.44 ,75,,,percent of total billed charges,75% of total billed charges,$135.44 ,75,,,percent of total billed charges,75% of total billed charges,$135.44 ,75,,,percent of total billed charges,75% of total billed charges,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.46 ,80,,,percent of total billed charges,80% of total billed charges,$57.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.21 ,$171.55 ,
11762 Reconstruction of nail bed with graft,11762,CDM,450,RC,11762,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11765 Wedge excision of skin of nail fold,12860,CDM,983,RC,11765,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$46.70 ,100,,,fee schedule,100% Amerigroup fee schedule,$46.70 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$50.90 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$47.63 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$46.70 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$47.63 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$47.63 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$46.70 ,$50.90 ,
"11982 Removal, non-biodegradable drug delivery implant",11982,CDM,361,RC,11982,HCPCS,outpatient,,,$253.00 ,$88.55 ,,$135.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.75 ,75,,,percent of total billed charges,75% of total billed charges,$189.75 ,75,,,percent of total billed charges,75% of total billed charges,$189.75 ,75,,,percent of total billed charges,75% of total billed charges,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$202.40 ,80,,,percent of total billed charges,80% of total billed charges,$80.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$202.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$194.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$227.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$240.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$189.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.34 ,$240.35 ,
"12013 Simple repair of wounds of face, ears, eyelids, nose, lips, mucous membra; 2.6-5.0cm",5043,CDM,450,RC,12013,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
"12014 Simple repair of wounds of face, ears, eyelids, nose, lips, mucous membra; 5.1-7.5cm",12862,CDM,450,RC,12014,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<-Tech Fee,12041,CDM,361,RC,12041,HCPCS,outpatient,,,$484.00 ,$169.40 ,,$259.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$259.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$363.00 ,75,,,percent of total billed charges,75% of total billed charges,$363.00 ,75,,,percent of total billed charges,75% of total billed charges,$363.00 ,75,,,percent of total billed charges,75% of total billed charges,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.20 ,80,,,percent of total billed charges,80% of total billed charges,$153.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$169.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$387.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$338.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$372.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$150.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$435.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$97.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$459.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$387.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$363.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$411.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.38 ,$459.80 ,
"13100 Repair, complex, trunk; 1.1 cm to 2.5 cm",13100,CDM,361,RC,13100,HCPCS,outpatient,,,$670.00 ,$234.50 ,,$359.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$359.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$502.50 ,75,,,percent of total billed charges,75% of total billed charges,$502.50 ,75,,,percent of total billed charges,75% of total billed charges,$502.50 ,75,,,percent of total billed charges,75% of total billed charges,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.00 ,80,,,percent of total billed charges,80% of total billed charges,$211.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$234.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$536.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$469.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$515.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$207.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$603.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$134.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$636.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$133.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$623.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$502.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$502.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$502.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$134.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$569.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.65 ,$636.50 ,
13101 REPAIR OF WOUND OR LESION,13101,CDM,361,RC,13101,HCPCS,outpatient,,,$823.00 ,$288.05 ,,$441.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$441.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$617.25 ,75,,,percent of total billed charges,75% of total billed charges,$617.25 ,75,,,percent of total billed charges,75% of total billed charges,$617.25 ,75,,,percent of total billed charges,75% of total billed charges,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$658.40 ,80,,,percent of total billed charges,80% of total billed charges,$260.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$288.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$658.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$576.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$576.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$633.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$255.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$740.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$165.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$781.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$658.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$765.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$617.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$699.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.49 ,$781.85 ,
"13120 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm",13120,CDM,361,RC,13120,HCPCS,outpatient,,,$772.00 ,$270.20 ,,$413.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$413.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$579.00 ,75,,,percent of total billed charges,75% of total billed charges,$579.00 ,75,,,percent of total billed charges,75% of total billed charges,$579.00 ,75,,,percent of total billed charges,75% of total billed charges,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$617.60 ,80,,,percent of total billed charges,80% of total billed charges,$244.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$270.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$617.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$540.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$540.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$594.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$239.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$694.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$155.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$733.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$717.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$579.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$579.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$579.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$656.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.54 ,$733.40 ,
"13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm",13121,CDM,361,RC,13121,HCPCS,outpatient,,,$860.00 ,$301.00 ,,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$301.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$662.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$266.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$774.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$817.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$799.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$167.70 ,$817.00 ,
"13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less",13122,CDM,361,RC,13122,HCPCS,outpatient,,,$280.00 ,$98.00 ,,$150.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.00 ,75,,,percent of total billed charges,75% of total billed charges,$210.00 ,75,,,percent of total billed charges,75% of total billed charges,$210.00 ,75,,,percent of total billed charges,75% of total billed charges,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.00 ,80,,,percent of total billed charges,80% of total billed charges,$88.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$215.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$86.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.60 ,$266.00 ,
"15240 Full thickness graft, free; forehead, cheeks, chin, mouth, neck, axillae, hands; <20 sq cm",15240,CDM,450,RC,15240,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
17110 Destruction of benign lesions; 1-14 lesions,17110,CDM,983,RC,17110,HCPCS,outpatient,,,$189.90 ,$66.47 ,,$43.88 ,100,,,fee schedule,100% Amerigroup fee schedule,$43.88 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$47.83 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$44.76 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$43.88 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$45.20 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$44.76 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$45.20 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$44.76 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$43.88 ,$47.83 ,
"17111 Destruct (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement),",17111,CDM,361,RC,17111,HCPCS,outpatient,,,$271.00 ,$94.85 ,,$145.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$203.25 ,75,,,percent of total billed charges,75% of total billed charges,$203.25 ,75,,,percent of total billed charges,75% of total billed charges,$203.25 ,75,,,percent of total billed charges,75% of total billed charges,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.80 ,80,,,percent of total billed charges,80% of total billed charges,$85.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$94.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$216.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$208.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$243.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$257.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$203.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$203.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$203.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$230.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.85 ,$257.45 ,
"17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)",,CDM,360,RC,17250,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"19081 Biopsy, breast, w/ localization device; first lesion, including stereotactic guidance",19081,CDM,402,RC,19081,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
20100 Exploration of penetrating wound (separate procedure); neck,20100,CDM,450,RC,20100,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"20206 Biopsy, muscle, percutaneous needle",20206,CDM,361,RC,20206,HCPCS,outpatient,,,$192.00 ,$67.20 ,,$102.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$102.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$144.00 ,75,,,percent of total billed charges,75% of total billed charges,$144.00 ,75,,,percent of total billed charges,75% of total billed charges,$144.00 ,75,,,percent of total billed charges,75% of total billed charges,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.60 ,80,,,percent of total billed charges,80% of total billed charges,$60.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$147.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$59.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$172.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$144.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$163.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.44 ,$182.40 ,
20501 Injection of sinus tract; diagnostic,20501,CDM,450,RC,20501,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20525 Removal of foreign body in muscle or tendon sheath; deep or complicated,20525,CDM,450,RC,20525,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"20550 Injection(s); single tendon sheath, or ligament, aponeurosis-Tech Fee",20550,CDM,450,RC,20550,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
20612 Aspiration and/or injection of ganglion cyst(s) any location,20612,CDM,361,RC,20612,HCPCS,outpatient,,,$139.00 ,$48.65 ,,$74.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.20 ,80,,,percent of total billed charges,80% of total billed charges,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$125.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.11 ,$132.05 ,
"23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia",23650,CDM,361,RC,23650,HCPCS,outpatient,,,"$1,024.00 ",$358.40 ,,$548.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$548.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$768.00 ,75,,,percent of total billed charges,75% of total billed charges,$768.00 ,75,,,percent of total billed charges,75% of total billed charges,$768.00 ,75,,,percent of total billed charges,75% of total billed charges,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.20 ,80,,,percent of total billed charges,80% of total billed charges,$323.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$358.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$819.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$716.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$788.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$320.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$317.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$921.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$205.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$972.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$203.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$768.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$768.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$768.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$205.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$870.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$199.68 ,$972.80 ,
"23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia",23655,CDM,361,RC,23655,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"26770 Closed treatment of interphalangeal joint dislocation, single, with manip; w/o anesthesia",26770,CDM,361,RC,26770,HCPCS,outpatient,,,$897.00 ,$313.95 ,,$480.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$480.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$672.75 ,75,,,percent of total billed charges,75% of total billed charges,$672.75 ,75,,,percent of total billed charges,75% of total billed charges,$672.75 ,75,,,percent of total billed charges,75% of total billed charges,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$717.60 ,80,,,percent of total billed charges,80% of total billed charges,$283.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$313.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$717.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$627.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$627.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$690.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$278.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$807.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$180.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$852.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$717.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$178.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$834.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$672.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$672.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$672.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$180.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$762.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$174.92 ,$852.15 ,
"26775 Closed treatment of interphalangeal joint dislocation single, with manip; requiring anesthesia",26775,CDM,361,RC,26775,HCPCS,outpatient,,,"$1,207.00 ",$422.45 ,,$646.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$646.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$905.25 ,75,,,percent of total billed charges,75% of total billed charges,$905.25 ,75,,,percent of total billed charges,75% of total billed charges,$905.25 ,75,,,percent of total billed charges,75% of total billed charges,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$965.60 ,80,,,percent of total billed charges,80% of total billed charges,$381.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$422.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$965.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$844.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$929.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$374.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,086.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$242.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,146.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$965.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$240.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,122.51 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$905.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$905.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$905.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$242.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,025.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$235.37 ,"$1,146.65 ",
"27197 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), w/o manipulation",27197,CDM,450,RC,27197,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
28630-Metatarsophalangeal w/o Anesthesia,28630,CDM,361,RC,28630,HCPCS,outpatient,,,$376.00 ,$131.60 ,,$201.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$201.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$282.00 ,75,,,percent of total billed charges,75% of total billed charges,$282.00 ,75,,,percent of total billed charges,75% of total billed charges,$282.00 ,75,,,percent of total billed charges,75% of total billed charges,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.80 ,80,,,percent of total billed charges,80% of total billed charges,$118.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$131.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$263.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$289.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$116.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$338.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$75.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$357.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$74.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$349.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$282.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$282.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$282.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$319.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.32 ,$357.20 ,
29130 – Application of Finger Splint ,29130,CDM,450,RC,29130,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
"30000 Drainage abscess or hematoma, nasal, internal approach",30000,CDM,450,RC,30000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"30020 Drainage abscess or hematoma, nasal septum",30020,CDM,450,RC,30020,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
"30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method",12861,CDM,450,RC,30901,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.26 ,$103.55 ,
"30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method",30903,CDM,361,RC,30903,HCPCS,outpatient,,,$267.00 ,$93.45 ,,$143.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$143.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$200.25 ,75,,,percent of total billed charges,75% of total billed charges,$200.25 ,75,,,percent of total billed charges,75% of total billed charges,$200.25 ,75,,,percent of total billed charges,75% of total billed charges,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.60 ,80,,,percent of total billed charges,80% of total billed charges,$84.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$93.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$213.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$186.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$205.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$82.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$240.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$253.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$200.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$200.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$200.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$226.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.07 ,$253.65 ,
"30905 CONTROL NASAL HEMOR,POSTERIOR- ER SERV P",,CDM,361,RC,30905,HCPCS,outpatient,,,$364.00 ,$127.40 ,,$195.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$195.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$291.20 ,80,,,percent of total billed charges,80% of total billed charges,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$127.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$291.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$254.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$280.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$112.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$327.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$73.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$345.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.98 ,$345.80 ,
32551 INSERTION OF CHEST TUBE,32551,CDM,361,RC,32551,HCPCS,outpatient,,,$530.00 ,$185.50 ,,$284.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$284.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$397.50 ,75,,,percent of total billed charges,75% of total billed charges,$397.50 ,75,,,percent of total billed charges,75% of total billed charges,$397.50 ,75,,,percent of total billed charges,75% of total billed charges,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$424.00 ,80,,,percent of total billed charges,80% of total billed charges,$167.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$185.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$424.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$371.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$371.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$164.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$477.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$106.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$503.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$397.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$397.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$397.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$450.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.35 ,$503.50 ,
"32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance",32555,CDM,361,RC,32555,HCPCS,outpatient,,,$371.00 ,$129.85 ,,$198.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$278.25 ,75,,,percent of total billed charges,75% of total billed charges,$278.25 ,75,,,percent of total billed charges,75% of total billed charges,$278.25 ,75,,,percent of total billed charges,75% of total billed charges,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$296.80 ,80,,,percent of total billed charges,80% of total billed charges,$117.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$129.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$259.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$285.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$115.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$333.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$74.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$352.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$345.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$278.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$278.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$278.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.35 ,$352.45 ,
"35201 Repair blood vessel, direct; neck",35201,CDM,450,RC,35201,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
36415 Collection of venous blood by venipuncture,36415,CDM,300,RC,36415,HCPCS,outpatient,,,$4.68 ,$1.64 ,,$2.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$2.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$2.34 ,75,,,percent of total billed charges,75% of total billed charges,$2.34 ,75,,,percent of total billed charges,75% of total billed charges,$2.34 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,80,,,percent of total billed charges,80% of total billed charges,$1.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$1.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$0.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$4.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$0.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$3.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$0.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$3.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$0.91 ,$8.74 ,
"36430 Transfusion, blood or blood components",36430,CDM,391,RC,36430,HCPCS,outpatient,,,$407.75 ,$142.71 ,,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$142.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$313.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$127.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$126.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$366.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$387.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$379.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.51 ,$387.36 ,
36561 INSERT TUNNELED CV CATH W/ PORT,36561,CDM,361,RC,36561,HCPCS,outpatient,,,"$1,122.00 ",$392.70 ,,$601.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$601.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$841.50 ,75,,,percent of total billed charges,75% of total billed charges,$841.50 ,75,,,percent of total billed charges,75% of total billed charges,$841.50 ,75,,,percent of total billed charges,75% of total billed charges,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$897.60 ,80,,,percent of total billed charges,80% of total billed charges,$354.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$897.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$785.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$785.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$863.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$351.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,009.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$225.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,065.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$897.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$223.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,043.46 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$841.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$841.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$841.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$225.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$953.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.79 ,"$1,065.90 ",
36563 Insertion of tunneled central venous access device,36563,CDM,361,RC,36563,HCPCS,outpatient,,,"$1,233.00 ",$431.55 ,,$660.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$660.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$924.75 ,75,,,percent of total billed charges,75% of total billed charges,$924.75 ,75,,,percent of total billed charges,75% of total billed charges,$924.75 ,75,,,percent of total billed charges,75% of total billed charges,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$986.40 ,80,,,percent of total billed charges,80% of total billed charges,$389.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$431.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$986.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$863.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$863.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$949.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$386.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$382.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,109.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$247.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,171.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$986.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,146.69 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$924.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$924.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$924.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$247.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,048.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.44 ,"$1,171.35 ",
"36571 Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5",36571,CDM,361,RC,36571,HCPCS,outpatient,,,"$1,054.00 ",$368.90 ,,$564.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$564.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$790.50 ,75,,,percent of total billed charges,75% of total billed charges,$790.50 ,75,,,percent of total billed charges,75% of total billed charges,$790.50 ,75,,,percent of total billed charges,75% of total billed charges,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$843.20 ,80,,,percent of total billed charges,80% of total billed charges,$333.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$368.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$843.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$737.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$737.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$811.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$326.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$948.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$211.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,001.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$980.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$790.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$790.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$790.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$211.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$895.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$205.53 ,"$1,001.30 ",
36573 PICC LINE W/IMAGING,36573,CDM,361,RC,36573,HCPCS,outpatient,,,$285.00 ,$99.75 ,,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$99.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$219.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$88.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$256.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$270.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.58 ,$270.75 ,
"36575 Repair tunneled/non-tunneled central cath, w/o subcut port/pump, central/periph insert site",36575,CDM,361,RC,36575,HCPCS,outpatient,,,$113.00 ,$39.55 ,,$60.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$84.75 ,75,,,percent of total billed charges,75% of total billed charges,$84.75 ,75,,,percent of total billed charges,75% of total billed charges,$84.75 ,75,,,percent of total billed charges,75% of total billed charges,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.40 ,80,,,percent of total billed charges,80% of total billed charges,$35.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$101.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$84.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.04 ,$107.35 ,
36578 REPLACE TUNNELED CV CATH,36578,CDM,361,RC,36578,HCPCS,outpatient,,,$686.00 ,$240.10 ,,$367.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$367.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$514.50 ,75,,,percent of total billed charges,75% of total billed charges,$514.50 ,75,,,percent of total billed charges,75% of total billed charges,$514.50 ,75,,,percent of total billed charges,75% of total billed charges,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$548.80 ,80,,,percent of total billed charges,80% of total billed charges,$216.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$240.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$548.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$480.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$528.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$212.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$617.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$137.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$651.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$548.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$514.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$514.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$514.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$137.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$583.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.77 ,$651.70 ,
"36580 Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without s",36580,CDM,361,RC,36580,HCPCS,outpatient,,,$223.00 ,$78.05 ,,$119.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$167.25 ,75,,,percent of total billed charges,75% of total billed charges,$167.25 ,75,,,percent of total billed charges,75% of total billed charges,$167.25 ,75,,,percent of total billed charges,75% of total billed charges,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.40 ,80,,,percent of total billed charges,80% of total billed charges,$70.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$200.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$211.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.49 ,$211.85 ,
"36581 Replacement, tunneled centrally inserted central venous catheter, w/o subcutaneous port/pump",36581,CDM,361,RC,36581,HCPCS,outpatient,,,$614.00 ,$214.90 ,,$329.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$329.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$460.50 ,75,,,percent of total billed charges,75% of total billed charges,$460.50 ,75,,,percent of total billed charges,75% of total billed charges,$460.50 ,75,,,percent of total billed charges,75% of total billed charges,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.20 ,80,,,percent of total billed charges,80% of total billed charges,$194.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$214.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$491.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$429.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$429.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$472.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$552.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$583.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$571.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$460.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$460.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$460.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$521.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.73 ,$583.30 ,
"36584 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subc",36584,CDM,361,RC,36584,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
36590 Removal of Port a Cath,36590,CDM,450,RC,36590,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
"36625 Arterial catheterization or cannulation for sampling, monitoring or transfusion; cutdown",36625,CDM,361,RC,36625,HCPCS,outpatient,,,$360.00 ,$126.00 ,,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.20 ,$342.00 ,
41108 Biopsy of floor of mouth,41108,CDM,450,RC,41108,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"41599 UNLISTED PROC, TONGUE, MOUTH-ER SERV PRO",41599,CDM,450,RC,41599,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
43235  UPPR GI ENDOSCOPY,31000,CDM,750,RC,43235,HCPCS,outpatient,,,"$1,088.00 ",$380.80 ,,$583.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$583.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$816.00 ,75,,,percent of total billed charges,75% of total billed charges,$816.00 ,75,,,percent of total billed charges,75% of total billed charges,$816.00 ,75,,,percent of total billed charges,75% of total billed charges,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$870.40 ,80,,,percent of total billed charges,80% of total billed charges,$344.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$380.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$870.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$761.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$837.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$337.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$979.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$218.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,033.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$216.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$816.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$816.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$816.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$924.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.16 ,"$1,033.60 ",
"44970 LAPAROSCOPY, APPENDECTOMY",44970,CDM,361,RC,44970,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"45380 Colonoscopy, flexible; with biopsy, single or multiple",31003,CDM,750,RC,45380,HCPCS,outpatient,,,"$3,623.04 ","$1,268.06 ",,"$1,941.95 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,941.95 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,898.43 ",80,,,percent of total billed charges,80% of total billed charges,"$1,145.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,268.06 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,898.43 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,536.13 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,536.13 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,789.74 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$720.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,134.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$706.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,123.14 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,260.74 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$727.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,441.89 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,898.43 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$720.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,369.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,717.28 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$727.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,079.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$720.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$706.49 ,"$3,441.89 ",
47562  LAPAROSCOPIC CHOLECYSTECTOMY,47562,CDM,361,RC,47562,HCPCS,outpatient,,,"$2,253.00 ",$788.55 ,,"$1,207.61 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,207.61 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,802.40 ",80,,,percent of total billed charges,80% of total billed charges,$712.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$788.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,802.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,577.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,577.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,734.81 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$448.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$705.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$698.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,027.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$452.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,140.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,802.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$448.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,095.29 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,689.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$452.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,915.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$448.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$439.34 ,"$2,140.35 ",
49083 Abdominal paracentesis with imaging guidance;  (diagnostic or therapeutic),49083,CDM,361,RC,49083,HCPCS,outpatient,,,$357.00 ,$124.95 ,,$191.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$191.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$267.75 ,75,,,percent of total billed charges,75% of total billed charges,$267.75 ,75,,,percent of total billed charges,75% of total billed charges,$267.75 ,75,,,percent of total billed charges,75% of total billed charges,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$285.60 ,80,,,percent of total billed charges,80% of total billed charges,$112.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$124.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$249.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$274.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$110.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$321.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$71.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$339.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$332.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$267.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$267.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$267.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$303.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.62 ,$339.15 ,
"49592 RPR OF ANTERIOR ABD HERN(S),",49592,CDM,450,RC,49592,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"53620 Dilation of urethral stricture by passage of filiform and follower, male; initial",53620,CDM,450,RC,53620,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
54235 INJECTION OF CORPORA CAVERN-ER PROC,54235,CDM,450,RC,54235,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
55120 Removal of foreign body in scrotum,55120,CDM,450,RC,55120,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"55899 Unlisted procedure, male genital system",55899,CDM,450,RC,55899,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
56820 Colposcopy of the vulva;,56820,CDM,450,RC,56820,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
64450 INJECTION ANES OTHER PERIPHERAL NERVE/BR,64450,CDM,450,RC,64450,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
"65290 Repair of wound, extraocular muscle, tendon and/or Tenon's capsule",65290,CDM,450,RC,65290,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
66999 EYE IRRIGATION W/O FB REMOVAL-ER SERV PR,66999,CDM,450,RC,66999,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
69205 Removal foreign body from external auditory canal; with general anesthesia,69205,CDM,361,RC,69205,HCPCS,outpatient,,,$321.00 ,$112.35 ,,$172.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$256.80 ,80,,,percent of total billed charges,80% of total billed charges,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$224.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$288.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$304.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.60 ,$304.95 ,
69209 Ear Irrigation POC,69209,CDM,361,RC,69209,HCPCS,outpatient,,,$48.00 ,$16.80 ,,$25.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.40 ,80,,,percent of total billed charges,80% of total billed charges,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.36 ,$45.60 ,
81002 Urinalysis Dipstick,81002,CDM,300,RC,81002,HCPCS,outpatient,,,$31.46 ,$11.01 ,,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$25.17 ,80,,,percent of total billed charges,80% of total billed charges,$9.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.48 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.17 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.27 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.21 ,$29.89 ,
82962 Accucheck,82962,CDM,300,RC,82962,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$2.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.28 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.82 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.00 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.94 ,$3.82 ,
"85651 Sedimentation rate, erythrocyte; non-automated",85651,CDM,300,RC,85651,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$47.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,$90.25 ,
"88305 Surgical pathology, gross and microscopic examination",88305,CDM,312,RC,88305,HCPCS,outpatient,,,$212.00 ,$74.20 ,,$69.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$69.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.52 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$190.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$201.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$27.16 ,$201.40 ,
92610 SWALLOW EVALUATION Charge,10526273,CDM,444,RC,92610,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
92960 CARDIOVERSION - ER SERV PROCEDURE,92960,CDM,361,RC,92960,HCPCS,outpatient,,,$364.00 ,$127.40 ,,$195.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$195.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$273.00 ,75,,,percent of total billed charges,75% of total billed charges,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$291.20 ,80,,,percent of total billed charges,80% of total billed charges,$115.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$127.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$291.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$254.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$280.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$112.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$327.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$73.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$345.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.98 ,$345.80 ,
"94010 Spirometry, w/ graphic record, total/timed vital capacity, expiratory flow rate measurement(s)",94010,CDM,410,RC,94010,HCPCS,outpatient,,,$361.09 ,$126.38 ,,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$343.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.41 ,$343.04 ,
96521 Refilling and maintenance of portable pump,96521,CDM,240,RC,96521,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
97018 Paraffin bath,8040871,CDM,420,RC,97018,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
"97598 Debridement, open wound; each additional 20 sq cm, or part thereof",97598,CDM,450,RC,97598,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
98926 Osteopathic manipulative treatment (OMT); 3-4 body regions involved,98926,CDM,361,RC,98926,HCPCS,outpatient,,,$118.00 ,$41.30 ,,$63.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.50 ,75,,,percent of total billed charges,75% of total billed charges,$88.50 ,75,,,percent of total billed charges,75% of total billed charges,$88.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.40 ,80,,,percent of total billed charges,80% of total billed charges,$37.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$41.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$106.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$112.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$88.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$100.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.01 ,$112.10 ,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,98927,CDM,361,RC,98927,HCPCS,outpatient,,,$155.00 ,$54.25 ,,$83.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.00 ,80,,,percent of total billed charges,80% of total billed charges,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$139.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.23 ,$147.25 ,
98929 Osteopathic manipulative treatment (OMT); 9-10 body regions involved,98929,CDM,361,RC,98929,HCPCS,outpatient,,,$237.00 ,$82.95 ,,$127.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.75 ,75,,,percent of total billed charges,75% of total billed charges,$177.75 ,75,,,percent of total billed charges,75% of total billed charges,$177.75 ,75,,,percent of total billed charges,75% of total billed charges,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.60 ,80,,,percent of total billed charges,80% of total billed charges,$74.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$82.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$165.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$73.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$213.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$225.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$177.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$201.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.22 ,$225.15 ,
"99151  Moderate sedation services, initial 15 minutes, patient < 5 yrs",20354,CDM,370,RC,99151,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
"99152 Mod Sedation by physician providing therp/dx service; init 15min, age>=5 yrs",99152,CDM,361,RC,99152,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$23.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.25 ,75,,,percent of total billed charges,75% of total billed charges,$32.25 ,75,,,percent of total billed charges,75% of total billed charges,$32.25 ,75,,,percent of total billed charges,75% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.39 ,$40.85 ,
"99153 Moderate sedation services, each additional 15 minutes",99153,CDM,361,RC,99153,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
"99156 Moderate Sedation By A Different Physician, Initial 15 Minutes, Patient Age 5 Years Or Older",99156,CDM,361,RC,99156,HCPCS,outpatient,,,$260.00 ,$91.00 ,,$139.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$195.00 ,75,,,percent of total billed charges,75% of total billed charges,$195.00 ,75,,,percent of total billed charges,75% of total billed charges,$195.00 ,75,,,percent of total billed charges,75% of total billed charges,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.00 ,80,,,percent of total billed charges,80% of total billed charges,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$91.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$200.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$80.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$234.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$247.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.70 ,$247.00 ,
"99157 Moderate Sedation Provided By A Different Physician, Each Additional 15 Minutes",99157,CDM,361,RC,99157,HCPCS,outpatient,,,$211.00 ,$73.85 ,,$113.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.80 ,80,,,percent of total billed charges,80% of total billed charges,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$73.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$147.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$189.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.15 ,$200.45 ,
"99195 Phlebotomy, therapeutic",99195,CDM,940,RC,99195,HCPCS,outpatient,,,$168.00 ,$58.80 ,,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$151.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.76 ,$159.60 ,
99354 Suboxone 1st hr,,CDM,510,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99487 - COMPLEX CHRONIC CARE MANAGEMENT.,99487,CDM,510,RC,99487,HCPCS,outpatient,,,$258.00 ,$90.30 ,,$138.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$138.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,75,,,percent of total billed charges,75% of total billed charges,$193.50 ,75,,,percent of total billed charges,75% of total billed charges,$193.50 ,75,,,percent of total billed charges,75% of total billed charges,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.40 ,80,,,percent of total billed charges,80% of total billed charges,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$90.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$198.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$232.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.31 ,$245.10 ,
BASEBALL SPLINT PADDED SM,12691,CDM,270,RC,,HCPCS,outpatient,,,$20.00 ,$7.00 ,,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.90 ,$19.00 ,
Breath Alcohol NIDA,16006,CDM,300,RC,82075,HCPCS,outpatient,,,$29.00 ,$10.15 ,,$10.61 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.61 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$23.20 ,80,,,percent of total billed charges,80% of total billed charges,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.00 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.66 ,$30.60 ,
CBC w/ Diff POC,150554,CDM,305,RC,85025,HCPCS,outpatient,,,$140.16 ,$49.06 ,,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$70.08 ,75,,,percent of total billed charges,75% of total billed charges,$70.08 ,75,,,percent of total billed charges,75% of total billed charges,$70.08 ,75,,,percent of total billed charges,75% of total billed charges,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$112.13 ,80,,,percent of total billed charges,80% of total billed charges,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$126.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$133.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.97 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$119.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.77 ,$133.15 ,
Clinic Anemia,16141,CDM,301,RC,82747,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.87 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$17.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.60 ,$40.85 ,
Clinic No Charge Visit,28612,CDM,999,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Drug Screen POC,16052,CDM,300,RC,80307,HCPCS,outpatient,,,$45.00 ,$45.00 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.23 ,$79.51 ,
Drug Screening POC,16052D,CDM,300,RC,80307,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$61.16 ,$79.51 ,
FOLEY CATH TRAY 14FR,11983,CDM,270,RC,,HCPCS,outpatient,,,$66.75 ,$23.36 ,,$35.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.40 ,80,,,percent of total billed charges,80% of total billed charges,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.02 ,$63.41 ,
G0008 - Medicare influenza vaccine administration,264619,CDM,771,RC,G0008,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
G0103 Prostate cancer screening; prostate specific antigen test,16039,CDM,300,RC,G0103,HCPCS,outpatient,,,$173.00 ,$60.55 ,,$92.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$92.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.50 ,75,,,percent of total billed charges,75% of total billed charges,$86.50 ,75,,,percent of total billed charges,75% of total billed charges,$86.50 ,75,,,percent of total billed charges,75% of total billed charges,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$138.40 ,80,,,percent of total billed charges,80% of total billed charges,$54.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$138.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$121.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.70 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$19.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$155.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$164.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$129.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$129.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$129.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.47 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$147.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.31 ,$164.35 ,
G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an optometr,G0118,CDM,361,RC,G0118,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
H Pylori POC,78338,CDM,300,RC,87338,HCPCS,outpatient,,,$219.00 ,$76.65 ,,$18.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$109.50 ,75,,,percent of total billed charges,75% of total billed charges,$109.50 ,75,,,percent of total billed charges,75% of total billed charges,$109.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$175.20 ,80,,,percent of total billed charges,80% of total billed charges,$69.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$175.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$168.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.09 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.38 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$197.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$208.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$164.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.63 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$186.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.38 ,$208.05 ,
"J1817 Insulin for administration through dme (i.e., insulin pump) per 50 units",J1817,CDM,637,RC,J1817,HCPCS,outpatient,,,$32.00 ,$11.20 ,,$17.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.60 ,80,,,percent of total billed charges,80% of total billed charges,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.24 ,$30.40 ,
"J2405 Injection, ondansetron hydrochloride, per 1 mg",J2405,CDM,250,RC,J2405,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$0.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$0.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$0.11 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.11 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.11 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$0.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$0.11 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$0.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.11 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$0.09 ,$9.50 ,
KNEE IMMOBIL 12 VELFOAM,28670,CDM,270,RC,,HCPCS,outpatient,,,$126.00 ,$44.10 ,,$67.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.50 ,75,,,percent of total billed charges,75% of total billed charges,$94.50 ,75,,,percent of total billed charges,75% of total billed charges,$94.50 ,75,,,percent of total billed charges,75% of total billed charges,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.80 ,80,,,percent of total billed charges,80% of total billed charges,$39.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$113.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$94.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.57 ,$119.70 ,
Medihoney,30160,CDM,270,RC,,HCPCS,outpatient,,,$35.04 ,$12.26 ,,$18.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.28 ,75,,,percent of total billed charges,75% of total billed charges,$26.28 ,75,,,percent of total billed charges,75% of total billed charges,$26.28 ,75,,,percent of total billed charges,75% of total billed charges,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.03 ,80,,,percent of total billed charges,80% of total billed charges,$11.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.29 ,
Misc. Procedure,30246,CDM,450,RC,,HCPCS,outpatient,,,"$1,495.41 ",$523.39 ,,$801.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$801.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$523.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,046.79 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,046.79 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,151.47 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$468.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$463.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,345.87 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$300.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,420.64 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,390.73 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$291.60 ,"$1,420.64 ",
TREATMENT ROOM,1004,CDM,761,RC,99211,HCPCS,outpatient,,,$77.94 ,$27.28 ,,$41.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.46 ,75,,,percent of total billed charges,75% of total billed charges,$58.46 ,75,,,percent of total billed charges,75% of total billed charges,$58.46 ,75,,,percent of total billed charges,75% of total billed charges,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.35 ,80,,,percent of total billed charges,80% of total billed charges,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$27.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$70.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.20 ,$74.04 ,
Tetanus/Diphtheria (Td),30137,CDM,771,RC,,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
WIPES SKIN BARRIER CAVILON NO-STING,30164,CDM,250,RC,,HCPCS,outpatient,,,$16.00 ,$5.60 ,,$8.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.80 ,80,,,percent of total billed charges,80% of total billed charges,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.12 ,$15.20 ,
bacitracin topical Ointment,24084,CDM,637,RC,A9270,HCPCS,outpatient,,,$149.00 ,$52.15 ,,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$134.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.06 ,$141.55 ,
88173 AP Bill Cytopath eval fna report,16167,CDM,311,RC,88173,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$96.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$96.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$96.16 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.41 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.58 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$33.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$119.05 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.41 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.33 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.41 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$33.79 ,$119.05 ,
"36566 - Insert tunneled centrally inserted central venous access device, w/ subQ port(s)",36566,CDM,361,RC,36566,HCPCS,outpatient,,,"$1,208.00 ",$422.80 ,,$647.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$647.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$906.00 ,75,,,percent of total billed charges,75% of total billed charges,$906.00 ,75,,,percent of total billed charges,75% of total billed charges,$906.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$966.40 ,80,,,percent of total billed charges,80% of total billed charges,$381.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$422.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$966.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$845.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$930.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$374.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,087.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$242.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,147.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$966.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$240.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.44 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$906.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$906.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$906.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$242.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,026.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$235.56 ,"$1,147.60 ",
36585 REPLACE PICVAD CATH W/PORT THROUGH ACCESS SITE,36585,CDM,361,RC,36585,HCPCS,outpatient,,,$946.00 ,$331.10 ,,$507.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$507.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$709.50 ,75,,,percent of total billed charges,75% of total billed charges,$709.50 ,75,,,percent of total billed charges,75% of total billed charges,$709.50 ,75,,,percent of total billed charges,75% of total billed charges,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$756.80 ,80,,,percent of total billed charges,80% of total billed charges,$299.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$331.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$756.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$662.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$728.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$293.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$851.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$189.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$898.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$756.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$879.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$709.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$709.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$709.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$804.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.47 ,$898.70 ,
ANESTHESIA EXTREME AGE,6013,CDM,370,RC,99100,HCPCS,outpatient,,,$104.00 ,$36.40 ,,$55.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.20 ,80,,,percent of total billed charges,80% of total billed charges,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$93.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.28 ,$98.80 ,
ANESTHESIA PAIN MANGMT,12597,CDM,370,RC,,HCPCS,outpatient,,,$119.00 ,$41.65 ,,$63.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$89.25 ,75,,,percent of total billed charges,75% of total billed charges,$89.25 ,75,,,percent of total billed charges,75% of total billed charges,$89.25 ,75,,,percent of total billed charges,75% of total billed charges,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.20 ,80,,,percent of total billed charges,80% of total billed charges,$37.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$41.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$107.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$89.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$89.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$89.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$101.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.21 ,$113.05 ,
ARTERIAL CATHETERIZATION,6012,CDM,370,RC,36620,HCPCS,outpatient,,,$283.00 ,$99.05 ,,$151.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$151.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$212.25 ,75,,,percent of total billed charges,75% of total billed charges,$212.25 ,75,,,percent of total billed charges,75% of total billed charges,$212.25 ,75,,,percent of total billed charges,75% of total billed charges,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$226.40 ,80,,,percent of total billed charges,80% of total billed charges,$89.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$99.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$226.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$198.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$217.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$254.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$268.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$212.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$212.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$212.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$240.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.19 ,$268.85 ,
Anesthesia Technical Fee,302152,CDM,370,RC,,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
Anesthesia Technical Fee,302151,CDM,370,RC,,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
EPIDURAL DAILY MANGMT,12534,CDM,370,RC,1996,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$17.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.44 ,$31.35 ,
EPIDURAL POST-OP,6017,CDM,370,RC,62319,HCPCS,outpatient,,,$837.00 ,$292.95 ,,$448.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$448.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$627.75 ,75,,,percent of total billed charges,75% of total billed charges,$627.75 ,75,,,percent of total billed charges,75% of total billed charges,$627.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$669.60 ,80,,,percent of total billed charges,80% of total billed charges,$264.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$292.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$669.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$585.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$585.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$644.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$259.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$753.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$168.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$795.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$669.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$166.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$778.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$627.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$627.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$627.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$711.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.22 ,$795.15 ,
NITROUS OXIDE,7057,CDM,370,RC,,HCPCS,outpatient,,,$24.00 ,$8.40 ,,$12.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.20 ,80,,,percent of total billed charges,80% of total billed charges,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.68 ,$22.80 ,
PAIN MANGT INJ 10 UNITS,12571,CDM,370,RC,,HCPCS,outpatient,,,"$1,037.00 ",$362.95 ,,$555.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$555.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.75 ,75,,,percent of total billed charges,75% of total billed charges,$777.75 ,75,,,percent of total billed charges,75% of total billed charges,$777.75 ,75,,,percent of total billed charges,75% of total billed charges,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$829.60 ,80,,,percent of total billed charges,80% of total billed charges,$327.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$362.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$725.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$798.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$324.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$321.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$933.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$208.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$985.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$206.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$964.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$777.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$777.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$777.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$208.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$881.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$202.22 ,$985.15 ,
REPAIR OF HERNIA UPPER ABDOMEN  - 00750,30261,CDM,964,RC,750,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
VENIPUNCTURE - ANES,6011,CDM,370,RC,36410,HCPCS,outpatient,,,$105.00 ,$36.75 ,,$56.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.75 ,75,,,percent of total billed charges,75% of total billed charges,$78.75 ,75,,,percent of total billed charges,75% of total billed charges,$78.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.00 ,80,,,percent of total billed charges,80% of total billed charges,$33.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$94.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$89.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.48 ,$99.75 ,
36592 Blood Collection using Central or Peripheral venous catheter,36592,CDM,361,RC,36592,HCPCS,outpatient,,,$91.00 ,$31.85 ,,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$81.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.75 ,$86.45 ,
.Post TR ABO/Rh,10622467,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
.Post TR DAT,10622468,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
.Pre TR DAT,10622469,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36430 BLOOD ADM,36430,CDM,391,RC,36430,HCPCS,outpatient,,,$407.75 ,$142.71 ,,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$305.81 ,75,,,percent of total billed charges,75% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges,$128.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$142.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$285.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$313.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$127.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$126.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$366.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$387.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$379.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$346.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.51 ,$387.36 ,
ABO Only,150171,CDM,300,RC,86900,HCPCS,outpatient,,,$234.52 ,$82.08 ,,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$187.62 ,80,,,percent of total billed charges,80% of total billed charges,$74.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.94 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$211.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$222.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$222.79 ,
ABO Only 2,150171,CDM,300,RC,86900,HCPCS,outpatient,,,$234.52 ,$82.08 ,,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$187.62 ,80,,,percent of total billed charges,80% of total billed charges,$74.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.94 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$211.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$222.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$222.79 ,
ABO/Rh,15017,CDM,300,RC,86900,HCPCS,outpatient,,,$234.52 ,$82.08 ,,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$187.62 ,80,,,percent of total billed charges,80% of total billed charges,$74.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.94 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$211.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$222.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$222.79 ,
ABO/Rh 2,15017,CDM,300,RC,86900,HCPCS,outpatient,,,$234.52 ,$82.08 ,,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.94 ,100,,,fee schedule,100% Amerigroup fee schedule,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$117.26 ,75,,,percent of total billed charges,75% of total billed charges,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$187.62 ,80,,,percent of total billed charges,80% of total billed charges,$74.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.94 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$211.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$222.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$199.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$222.79 ,
ABO/Rh Retype,15797,CDM,300,RC,86902,HCPCS,outpatient,,,$328.00 ,$114.80 ,,$175.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$175.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$262.40 ,80,,,percent of total billed charges,80% of total billed charges,$103.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.52 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$262.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$229.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.30 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.35 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$295.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$311.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.39 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.30 ,$311.60 ,
Antibody Identification TC,,CDM,300,RC,86870,HCPCS,outpatient,,,$110.00 ,$38.50 ,,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$55.00 ,75,,,percent of total billed charges,75% of total billed charges,$55.00 ,75,,,percent of total billed charges,75% of total billed charges,$55.00 ,75,,,percent of total billed charges,75% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.43 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.12 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$104.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.30 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.12 ,$104.50 ,
Antibody Screen Gel 2,1524611,CDM,300,RC,86850,HCPCS,outpatient,,,$154.55 ,$54.09 ,,$15.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$123.64 ,80,,,percent of total billed charges,80% of total billed charges,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$123.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.53 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.23 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$146.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.53 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.53 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.77 ,$146.82 ,
Antibody Screen Tube,15246,CDM,300,RC,86870,HCPCS,outpatient,,,$154.55 ,$54.09 ,,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$77.28 ,75,,,percent of total billed charges,75% of total billed charges,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.64 ,80,,,percent of total billed charges,80% of total billed charges,$48.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.43 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.12 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$47.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$139.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$146.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.30 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$131.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.12 ,$146.82 ,
Bill Only 86920 Crossmatch Immed Spin 1 Unit,86920,CDM,300,RC,86920,HCPCS,outpatient,,,$212.00 ,$74.20 ,,$21.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$190.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$201.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.17 ,$201.40 ,
Crossmatch,15004,CDM,300,RC,86922,HCPCS,outpatient,,,$261.12 ,$91.39 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$130.56 ,75,,,percent of total billed charges,75% of total billed charges,$130.56 ,75,,,percent of total billed charges,75% of total billed charges,$130.56 ,75,,,percent of total billed charges,75% of total billed charges,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.90 ,80,,,percent of total billed charges,80% of total billed charges,$82.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$91.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$201.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$80.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$235.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$248.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$195.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$221.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$248.06 ,
DAT IgG Tube,7032170,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
DAT IgG/C3,28710,CDM,300,RC,86880,HCPCS,outpatient,,,$49.00 ,$17.15 ,,$7.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.50 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.20 ,80,,,percent of total billed charges,80% of total billed charges,$15.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.89 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.75 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.39 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.78 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.89 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.89 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.39 ,$46.55 ,
DAT Poly Tube,8036616,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
E0379 RBC CP2D AS3 500 LR Irr,154011,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E0382 RBC CP2D AS3 500 LR,154012,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E0713 FFP CP2D,151581,CDM,390,RC,,HCPCS,outpatient,,,$167.00 ,$58.45 ,,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$128.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$150.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.57 ,$158.65 ,
E0869 Aph FFP ACDA,151582,CDM,390,RC,,HCPCS,outpatient,,,$167.00 ,$58.45 ,,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$128.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$150.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.57 ,$158.65 ,
E1624 Aph Plasma ACDA <24h,151585,CDM,390,RC,,HCPCS,outpatient,,,$167.00 ,$58.45 ,,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$128.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$150.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.57 ,$158.65 ,
E2619 Plasma CP2D <24h,151588,CDM,390,RC,,HCPCS,outpatient,,,$167.00 ,$58.45 ,,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$89.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$125.25 ,75,,,percent of total billed charges,75% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges,$52.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$128.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$150.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.57 ,$158.65 ,
E4527 Aph RBC ACDA AS1 LR Irr 1,154013,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E4528 Aph RBC ACDA AS1 LR Irr 2,154014,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E4532 Aph RBC ACDA AS1 LR 1,154015,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E4533 Aph RBC ACDA AS1 LR 2,15401,CDM,390,RC,,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
E5032 Aph Plt ACDA LR Bm 2,158333,CDM,390,RC,,HCPCS,outpatient,,,"$1,120.00 ",$392.00 ,,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$862.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,008.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,064.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.40 ,"$1,064.00 ",
EA047 Pooled Plt CP2D LR BM >=36h,158332,CDM,390,RC,,HCPCS,outpatient,,,"$1,120.00 ",$392.00 ,,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$862.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,008.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,064.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.40 ,"$1,064.00 ",
EA137 Aph Plts ACDA>PASC LR BM>=36h 1,158335,CDM,390,RC,,HCPCS,outpatient,,,"$1,120.00 ",$392.00 ,,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$862.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,008.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,064.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.40 ,"$1,064.00 ",
EA138 Aph Plts ACDA>PASC LR BM>=36h 2,158338,CDM,390,RC,,HCPCS,outpatient,,,"$1,120.00 ",$392.00 ,,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$862.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,008.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,064.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.40 ,"$1,064.00 ",
EA139 Aph Plts ACDA>PASC LR BM>=36h 3,15833,CDM,390,RC,,HCPCS,outpatient,,,"$1,120.00 ",$392.00 ,,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$840.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges,$354.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$392.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$784.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$862.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$347.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,008.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,064.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$896.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$840.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$952.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.40 ,"$1,064.00 ",
P9016 RBC Leukopoor Ea Unit,P9016,CDM,390,RC,P9016,HCPCS,outpatient,,,$480.48 ,$168.17 ,,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges,$151.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.69 ,$456.46 ,
REF ABO/Rh,8036627,CDM,300,RC,86901,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.80 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$18.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.80 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.80 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$18.86 ,
REF Antibody ID,7032173,CDM,300,RC,86870,HCPCS,outpatient,,,$870.00 ,$304.50 ,,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.43 ,100,,,fee schedule,100% Amerigroup fee schedule,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$696.00 ,80,,,percent of total billed charges,80% of total billed charges,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.43 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$696.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$609.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$609.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$669.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.12 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$269.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$783.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$826.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$809.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.30 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.12 ,$826.50 ,
REF Antibody Screen,8124394,CDM,300,RC,86850,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.97 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.53 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.23 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$19.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.53 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.53 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.77 ,$19.80 ,
REF Crossmatch,8124406,CDM,300,RC,86920,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
REF Crossmatch -> Compatible,8208218,CDM,300,RC,86920,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
REF Crossmatch -> Least Incompatible,8208219,CDM,300,RC,86920,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Red Blood Cells,85041,CDM,300,RC,85041,HCPCS,outpatient,,,$328.00 ,$114.80 ,,$3.97 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.97 ,100,,,fee schedule,100% Amerigroup fee schedule,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$164.00 ,75,,,percent of total billed charges,75% of total billed charges,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$262.40 ,80,,,percent of total billed charges,80% of total billed charges,$103.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.97 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$262.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$229.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.05 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$295.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.91 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$311.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.89 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$278.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,$311.60 ,
Rh Only,15010,CDM,300,RC,86901,HCPCS,outpatient,,,$49.00 ,$17.15 ,,$15.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.20 ,80,,,percent of total billed charges,80% of total billed charges,$15.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.80 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.80 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.80 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.99 ,$46.55 ,
Serological Immediate Spin -> Compatible,15004,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
Serological Immediate Spin -> Corrected,150044,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
Serological Immediate Spin -> Incompatible,150045,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
Weak D,20386,CDM,300,RC,86885,HCPCS,outpatient,,,$197.00 ,$68.95 ,,$7.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$157.60 ,80,,,percent of total billed charges,80% of total billed charges,$62.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.55 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$157.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.19 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.72 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$177.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.35 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$187.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.33 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.72 ,$187.15 ,
XM AHG Tube Interp -> Incompatible,150046,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
XM AHG Tube Interp -> Corrected,150043,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
XM AHG Tube Interp -> Compatible,150041,CDM,300,RC,86922,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$136.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,$258.40 ,
94010 Pulmonary Function Test Charge,12019,CDM,410,RC,94010,HCPCS,outpatient,,,$361.09 ,$126.38 ,,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$343.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.41 ,$343.04 ,
Electrocardiogram 12 Lead,13001,CDM,730,RC,93005,HCPCS,outpatient,,,$194.23 ,$67.98 ,,$104.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.67 ,75,,,percent of total billed charges,75% of total billed charges,$145.67 ,75,,,percent of total billed charges,75% of total billed charges,$145.67 ,75,,,percent of total billed charges,75% of total billed charges,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.38 ,80,,,percent of total billed charges,80% of total billed charges,$61.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$135.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$60.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$174.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$145.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.87 ,$184.52 ,
94010 CLINIC ONLY - BASIC SPIROMETRY,20360,CDM,460,RC,94010,HCPCS,outpatient,,,$463.00 ,$162.05 ,,$248.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$370.40 ,80,,,percent of total billed charges,80% of total billed charges,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$162.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$324.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$324.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$356.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$143.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$416.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$92.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$439.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$92.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.29 ,$439.85 ,
94060 BRONCHOSPASM EVALUATION,20361,CDM,460,RC,94060,HCPCS,outpatient,,,$965.25 ,$337.84 ,,$517.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$517.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$772.20 ,80,,,percent of total billed charges,80% of total billed charges,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$337.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$772.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$675.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$675.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$743.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$299.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$868.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$193.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$916.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$897.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$193.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$188.22 ,$916.99 ,
94200 MVV/MEP/MLP,20364,CDM,460,RC,94200,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
94375 FLOW VOLUME LOOP CHARGE,20365,CDM,460,RC,94375,HCPCS,outpatient,,,$675.00 ,$236.25 ,,$361.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$361.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$506.25 ,75,,,percent of total billed charges,75% of total billed charges,$506.25 ,75,,,percent of total billed charges,75% of total billed charges,$506.25 ,75,,,percent of total billed charges,75% of total billed charges,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$540.00 ,80,,,percent of total billed charges,80% of total billed charges,$213.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$236.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$540.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$472.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$519.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$209.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$607.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$135.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$641.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$540.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$134.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$627.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$506.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$506.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$506.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$573.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.63 ,$641.25 ,
94618 PULMONARY STRESS TESTING,20366,CDM,460,RC,94618,HCPCS,outpatient,,,$219.18 ,$76.71 ,,$117.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$164.39 ,75,,,percent of total billed charges,75% of total billed charges,$164.39 ,75,,,percent of total billed charges,75% of total billed charges,$164.39 ,75,,,percent of total billed charges,75% of total billed charges,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.34 ,80,,,percent of total billed charges,80% of total billed charges,$69.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$76.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$168.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$197.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$208.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$164.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$186.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.74 ,$208.22 ,
94625 OP Pulmonary Rehab; without continuous oxi,94625,CDM,460,RC,94625,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
94640 MDI SUBSEQUENT CHARGE,20367,CDM,410,RC,94640,HCPCS,outpatient,,,$549.12 ,$192.19 ,,$294.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$294.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$439.30 ,80,,,percent of total billed charges,80% of total billed charges,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$192.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$384.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$422.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$170.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$494.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$110.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$521.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$510.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.08 ,$521.66 ,
94664 INITIAL SVN TREATMENT CHARGE,20368,CDM,410,RC,94664,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
94667 CHEST WALL PERC/VIB/PD,20369,CDM,410,RC,94667,HCPCS,outpatient,,,$400.00 ,$140.00 ,,$214.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$214.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.00 ,80,,,percent of total billed charges,80% of total billed charges,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$140.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$320.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$280.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$308.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$124.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$360.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$380.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$320.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.00 ,$380.00 ,
94668 CHEST WALL PERC/VIB/PD SUB,20370,CDM,410,RC,94668,HCPCS,outpatient,,,$400.00 ,$140.00 ,,$214.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$214.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$300.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.00 ,80,,,percent of total billed charges,80% of total billed charges,$126.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$140.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$320.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$280.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$308.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$124.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$360.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$380.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$320.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$340.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.00 ,$380.00 ,
94727 NITROGEN WASHOUT CHARGE,20362,CDM,460,RC,94727,HCPCS,outpatient,,,$375.00 ,$131.25 ,,$201.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$201.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$281.25 ,75,,,percent of total billed charges,75% of total billed charges,$281.25 ,75,,,percent of total billed charges,75% of total billed charges,$281.25 ,75,,,percent of total billed charges,75% of total billed charges,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.00 ,80,,,percent of total billed charges,80% of total billed charges,$118.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$131.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$262.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$288.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$116.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$337.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$75.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$356.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$74.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$281.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$318.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.13 ,$356.25 ,
94729 DIFFUSION CAPACITY CHARGE,20363,CDM,460,RC,94729,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
G0237 RESP STRENGTH TX 15 MIN IND,20373,CDM,410,RC,,HCPCS,outpatient,,,$85.80 ,$30.03 ,,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.73 ,$81.51 ,
G0238 OTH RESP PROC- INDIVIDUAL,20374,CDM,410,RC,,HCPCS,outpatient,,,$85.80 ,$30.03 ,,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.73 ,$81.51 ,
G0239 OTH RESP PROC- GROUP,20375,CDM,410,RC,,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
11111 - Suture Removal,28597,CDM,450,RC,11111,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33333 - Left Without Being Seen,28595,CDM,999,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"96360 - ED Hydration, first hour",263508,CDM,450,RC,96360,HCPCS,outpatient,,,$322.36 ,$112.83 ,,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$290.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.86 ,$306.24 ,
"96361- ED Hydration, each additional hour",20270,CDM,260,RC,96361,HCPCS,outpatient,,,$70.79 ,$24.78 ,,$37.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.63 ,80,,,percent of total billed charges,80% of total billed charges,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.80 ,$67.25 ,
"96365- ED IV tx, first hour",265794,CDM,260,RC,96365,HCPCS,outpatient,,,$206.57 ,$72.30 ,,$110.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.26 ,80,,,percent of total billed charges,80% of total billed charges,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$185.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.28 ,$196.24 ,
"96366- ED IV tx, each additional hour",20271,CDM,260,RC,96366,HCPCS,outpatient,,,$43.62 ,$15.27 ,,$23.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.72 ,75,,,percent of total billed charges,75% of total billed charges,$32.72 ,75,,,percent of total billed charges,75% of total billed charges,$32.72 ,75,,,percent of total billed charges,75% of total billed charges,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.90 ,80,,,percent of total billed charges,80% of total billed charges,$13.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.51 ,$41.44 ,
"96367- ED IV tx, sequential infusion",96367,CDM,260,RC,96367,HCPCS,outpatient,,,$151.58 ,$53.05 ,,$81.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.26 ,80,,,percent of total billed charges,80% of total billed charges,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$136.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.56 ,$144.00 ,
"96368- ED IV tx, concurrent infusion",20274,CDM,260,RC,96368,HCPCS,outpatient,,,$231.99 ,$81.20 ,,$124.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.59 ,80,,,percent of total billed charges,80% of total billed charges,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.24 ,$220.39 ,
96372- ED Subq/IM Injection,263504,CDM,450,RC,96372,HCPCS,outpatient,,,$193.92 ,$67.87 ,,$103.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.14 ,80,,,percent of total billed charges,80% of total billed charges,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$135.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$60.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$174.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.81 ,$184.22 ,
"96374-Injection, single/initial",96374,CDM,450,RC,96374,HCPCS,outpatient,,,$153.15 ,$53.60 ,,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$47.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$137.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.86 ,$145.49 ,
"96375-IV Injection, add new drug",20273,CDM,260,RC,96375,HCPCS,outpatient,,,$168.60 ,$59.01 ,,$90.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.45 ,75,,,percent of total billed charges,75% of total billed charges,$126.45 ,75,,,percent of total billed charges,75% of total billed charges,$126.45 ,75,,,percent of total billed charges,75% of total billed charges,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.88 ,80,,,percent of total billed charges,80% of total billed charges,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$151.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.88 ,$160.17 ,
"96376- ED IV Injection, add same drug",20272,CDM,260,RC,96376,HCPCS,outpatient,,,$85.80 ,$30.03 ,,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.73 ,$81.51 ,
"99281 ED VISIT FOR E&M PATIENT, LEV 1, MAY NOT REQ PRESENCE OF PHYSICIAN OR OTHER, CC",5101,CDM,450,RC,99281,HCPCS,outpatient,,,$75.09 ,$26.28 ,,$50.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.32 ,75,,,percent of total billed charges,75% of total billed charges,$56.32 ,75,,,percent of total billed charges,75% of total billed charges,$56.32 ,75,,,percent of total billed charges,75% of total billed charges,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.07 ,80,,,percent of total billed charges,80% of total billed charges,$23.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.64 ,$71.34 ,
"99282 ED VISIT E&M PATIENT, LEV 2, REQ MED APPROP HSTRY/EXAM/MDM, CC",5102,CDM,450,RC,99282,HCPCS,outpatient,,,$139.69 ,$48.89 ,,$74.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.77 ,75,,,percent of total billed charges,75% of total billed charges,$104.77 ,75,,,percent of total billed charges,75% of total billed charges,$104.77 ,75,,,percent of total billed charges,75% of total billed charges,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.75 ,80,,,percent of total billed charges,80% of total billed charges,$44.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$125.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$104.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.24 ,$132.71 ,
"99283 ED VISIT E&M PATIENT, LEV 3, REQ MED APPROP HSTRY/EXAM/LOW MDM, CC",5103,CDM,450,RC,99283,HCPCS,outpatient,,,$245.03 ,$85.76 ,,$131.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$183.77 ,75,,,percent of total billed charges,75% of total billed charges,$183.77 ,75,,,percent of total billed charges,75% of total billed charges,$183.77 ,75,,,percent of total billed charges,75% of total billed charges,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.02 ,80,,,percent of total billed charges,80% of total billed charges,$77.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$85.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$188.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$75.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$220.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$232.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$183.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$183.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$183.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$208.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.78 ,$232.78 ,
"99284 ED VISIT E&M PATIENT, LEV 4, REQ MED APPROP HSTRY/EXAM/MODERATE MDM, CC",5104,CDM,450,RC,99284,HCPCS,outpatient,,,$731.05 ,$255.87 ,,$391.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$391.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$548.29 ,75,,,percent of total billed charges,75% of total billed charges,$548.29 ,75,,,percent of total billed charges,75% of total billed charges,$548.29 ,75,,,percent of total billed charges,75% of total billed charges,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$584.84 ,80,,,percent of total billed charges,80% of total billed charges,$231.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$255.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$584.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$511.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$511.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$562.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$228.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$228.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$226.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$657.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$146.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$694.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$584.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$145.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$679.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$548.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$548.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$548.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$146.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$621.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$142.55 ,$694.50 ,
"99285 ED VISIT E&M PATIENT, LEV 5, REQ MED APPROP HSTRY/EXAM/HIGH MDM, CC",5105,CDM,450,RC,99285,HCPCS,outpatient,,,$548.11 ,$191.84 ,,$293.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$293.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.08 ,75,,,percent of total billed charges,75% of total billed charges,$411.08 ,75,,,percent of total billed charges,75% of total billed charges,$411.08 ,75,,,percent of total billed charges,75% of total billed charges,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$438.49 ,80,,,percent of total billed charges,80% of total billed charges,$173.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$191.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$383.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$422.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$169.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$493.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$110.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$520.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$411.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$465.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.88 ,$520.70 ,
99291 - Facility Level Critical Care Ill/Injured Patient Init 30-74 Min,5106,CDM,450,RC,99291,HCPCS,outpatient,,,"$2,698.00 ",$944.30 ,,"$1,446.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,446.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,158.40 ",80,,,percent of total billed charges,80% of total billed charges,$853.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$944.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,158.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,888.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,888.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,077.46 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$844.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$526.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$836.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,428.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$541.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,563.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,158.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$536.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,509.14 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,023.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$541.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,293.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$526.11 ,"$2,563.10 ",
G0108 DIABETES SELF MANAGEMENT TRAINING 30 MIN CHARGE,G0108,CDM,761,RC,G0108,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
85014 HEMATOCRIT CHARGE,85014,CDM,305,RC,85014,HCPCS,outpatient,,,$30.91 ,$10.82 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.73 ,80,,,percent of total billed charges,80% of total billed charges,$9.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$29.36 ,
85018 HEMOGLOBIN CHARGE,85018,CDM,305,RC,85018,HCPCS,outpatient,,,$15.73 ,$5.51 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.58 ,80,,,percent of total billed charges,80% of total billed charges,$4.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$14.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$14.94 ,
Prefabricated Splints,28670,CDM,270,RC,,HCPCS,outpatient,,,$80.00 ,$28.00 ,,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.00 ,80,,,percent of total billed charges,80% of total billed charges,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$72.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.60 ,$76.00 ,
11440 EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< ProFee,11440,CDM,450,RC,11440,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
16020 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL ProFee,16020,CDM,450,RC,16020,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
17003 DESTRUCTION PRE-MALIG AK 2-14 Clinic Charge ProFee,17003,CDM,361,RC,17003,HCPCS,outpatient,,,$7.00 ,$2.45 ,,$3.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$3.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.60 ,80,,,percent of total billed charges,80% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$2.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$2.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$6.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$1.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$6.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$1.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.37 ,$6.65 ,
28540 Reduce Disloc Tarsal ProFee,28540,CDM,361,RC,28540,HCPCS,outpatient,,,$587.00 ,$205.45 ,,$314.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$314.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$440.25 ,75,,,percent of total billed charges,75% of total billed charges,$440.25 ,75,,,percent of total billed charges,75% of total billed charges,$440.25 ,75,,,percent of total billed charges,75% of total billed charges,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$469.60 ,80,,,percent of total billed charges,80% of total billed charges,$185.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$205.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$410.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$451.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$181.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$528.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$117.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$557.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$440.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$440.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$440.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$498.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.47 ,$557.65 ,
"99152 ED Moderate Sedation, initial 15 min, patient age 5 yr or older",99155,CDM,361,RC,99155,HCPCS,outpatient,,,$285.00 ,$99.75 ,,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$99.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$219.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$88.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$256.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$270.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.58 ,$270.75 ,
"10021 Fine needle aspiration biopsy, w/o imaging guidance; 1st lesion",10021,CDM,450,RC,10021,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
10060 INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE TechFee,10060,CDM,450,RC,10060,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE TechFee,10061,CDM,450,RC,10061,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
10080 INCISION & DRAINAGE PILONIDAL CYST SIMPLE TechFee,10080,CDM,450,RC,10080,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
10081 INCISION & DRAINAGE PILONIDAL CYST COMPLICATED TechFee,10081,CDM,450,RC,10081,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
"10120 ER Incision & Removal of foreign body, subq, simple",10120,CDM,361,RC,10120,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
10121 INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL TechFee,10121,CDM,450,RC,10121,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee,10140,CDM,450,RC,10140,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
10160 PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST TechFee,10160,CDM,450,RC,10160,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
"10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION TechFee",10180,CDM,450,RC,10180,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
11000 DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF TechFee,11000,CDM,450,RC,11000,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11001 DEBRID EA ADD 10% BOD SUR TechFee,11001,CDM,450,RC,11001,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11010 DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS TechFee,11010,CDM,450,RC,11010,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"11011 DEBRIDE SKIN/MUSCLE, FX TechFee",11011,CDM,450,RC,11011,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11042 DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< TechFee,11042,CDM,450,RC,11042,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11043 DEBRIDE TISSUE/MUSCLE TechFee,11043,CDM,450,RC,11043,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11044 DEBRIDE TISSUE/MUSCLE/BONE TechFee,11044,CDM,450,RC,11044,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11045 EACH ADDITIONAL 20 CM TechFee,11045,CDM,450,RC,11045,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11046 EACH ADDITIONAL 20CM TechFee,11046,CDM,450,RC,11046,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
11047 DEBRIDEMENT BONEEACH ADDTIONAL 20CM TechFee,11047,CDM,450,RC,11047,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION 2 TO 4 LESIONS. TechFee,11056,CDM,450,RC,11056,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11200 REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 TechFee,11200,CDM,450,RC,11200,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
11400 EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/ TechFee,11400,CDM,450,RC,11400,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
11402 EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2.0 CM TechFee,11402,CDM,450,RC,11402,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11420 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< TechFee,11420,CDM,450,RC,11420,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11421 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM TechFee,11421,CDM,450,RC,11421,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"11443 Remove Lesion, Face/Lid/Ear/Nose/Lip 2.1 to 3.0 cm Charge TechFee",11443,CDM,450,RC,11443,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11719 TRIM NONDYSTROPHIC NAILS ANY # TechFee,11719,CDM,450,RC,11719,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11720 DEBRIDEMENT NAIL ANY METHOD 1-5 TechFee,11720,CDM,450,RC,11720,HCPCS,outpatient,,,$135.00 ,$47.25 ,,$72.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.00 ,80,,,percent of total billed charges,80% of total billed charges,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$47.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$94.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$103.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$121.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$128.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.33 ,$128.25 ,
11730 AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 TechFee,11730,CDM,450,RC,11730,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
"11732 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH AD TechFee",11732,CDM,450,RC,11732,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
11740-Evacuation of subungual hematoma,11740,CDM,450,RC,11740,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
11750 - REMOVAL OF NAIL BED,11750,CDM,450,RC,11750,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11760 REPAIR NAIL BED TechFee,11760,CDM,450,RC,11760,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
11765 WEDGE EXCISION SKIN NAIL FOLD TechFee,11765,CDM,450,RC,11765,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11976 REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES TechFee,11976,CDM,450,RC,11976,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
12001 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< TechFee,28770,CDM,450,RC,12001,HCPCS,outpatient,,,$615.39 ,$215.39 ,,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$215.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$473.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$553.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$584.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$572.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.00 ,$584.62 ,
12002 SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM TechFee,12002,CDM,450,RC,12002,HCPCS,outpatient,,,$227.61 ,$79.66 ,,$122.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.09 ,80,,,percent of total billed charges,80% of total billed charges,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$204.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$216.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.38 ,$216.23 ,
12004 SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM TechFee,12004,CDM,450,RC,12004,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12005 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM TechFee,12005,CDM,450,RC,12005,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM TechFee,12006,CDM,450,RC,12006,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12007 SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM TechFee,12007,CDM,450,RC,12007,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12011 Laceration Simple Face <2.6 CM,12011,CDM,450,RC,12011,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM TechFee,12013,CDM,450,RC,12013,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM TechFee,12014,CDM,450,RC,12014,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM TechFee,12015,CDM,450,RC,12015,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM TechFee,12016,CDM,450,RC,12016,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12017 SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM TechFee,12017,CDM,450,RC,12017,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
12018 SIMPLE REPAIR F/E/E/N/L/M >30.0 CM TechFee,,CDM,450,RC,12018,HCPCS,outpatient,,,$163.00 ,$57.05 ,,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.79 ,$154.85 ,
12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE TechFee,12020,CDM,450,RC,12020,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
12021 TX SUPERFICIAL WOUND DEHISCENCE W/PACKING TechFee,12021,CDM,450,RC,12021,HCPCS,outpatient,,,$163.00 ,$57.05 ,,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.79 ,$154.85 ,
12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< TechFee,12031,CDM,450,RC,12031,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM TechFee,12032,CDM,450,RC,12032,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM TechFee,12034,CDM,450,RC,12034,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
"12035  Repair, interm, wounds scalp, axillae, trunk and/or ext/ ED TechFee",12035,CDM,450,RC,12035,HCPCS,outpatient,,,$230.00 ,$80.50 ,,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.85 ,$218.50 ,
12036 REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM TechFee,12036,CDM,450,RC,12036,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12037 REPAIR INTERMEDIATE S/A/T/E >30.0 CM TechFee,12037,CDM,450,RC,12037,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12041 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< TechFee,12041,CDM,450,RC,12041,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12042 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM TechFee,12042,CDM,450,RC,12042,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
12044 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM TechFee,12044,CDM,450,RC,12044,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12045 REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM TechFee,12045,CDM,450,RC,12045,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12046 RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM TechFee,12046,CDM,450,RC,12046,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12047 REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM TechFee,12047,CDM,450,RC,12047,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12051 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< TechFee,12051,CDM,450,RC,12051,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12052 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM TechFee,12052,CDM,450,RC,12052,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12053 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM TechFee,12053,CDM,450,RC,12053,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12054 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM TechFee,12054,CDM,450,RC,12054,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12055 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM TechFee,12055,CDM,450,RC,12055,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12056 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM TechFee,12056,CDM,450,RC,12056,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12057 REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM TechFee,12057,CDM,450,RC,12057,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13100 REPAIR COMPLEX TRUNK 1.1-2.5 CM TechFee,13100,CDM,450,RC,13100,HCPCS,outpatient,,,$360.00 ,$126.00 ,,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.20 ,$342.00 ,
13101 REPAIR COMPLEX TRUNK 2.6-7.5 CM TechFee,13101,CDM,450,RC,13101,HCPCS,outpatient,,,$189.00 ,$66.15 ,,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$170.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.86 ,$179.55 ,
13102 REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/< TechFee,13102,CDM,450,RC,13102,HCPCS,outpatient,,,$230.00 ,$80.50 ,,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.85 ,$218.50 ,
"13121 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; 2.6 cm to 7.5 cm",13121,CDM,450,RC,13121,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
"13122 ED Tech Fee Repair, Complex, Scalp, Arms, and/or Legs; each add 5 cm or less",13122,CDM,450,RC,13122,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM TechFee,13131,CDM,450,RC,13131,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13133 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< TechFee,13133,CDM,450,RC,13133,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
"13150 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.0 CM OR LESS TechFee",13150,CDM,450,RC,13150,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM TechFee,13151,CDM,450,RC,13151,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13152 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM TechFee,13152,CDM,450,RC,13152,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13153 REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/ TechFee,13153,CDM,450,RC,13153,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
14040 SKIN PLASTY TechFee,14040,CDM,450,RC,14040,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
16025 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM TechFee,16025,CDM,450,RC,16025,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
16030 DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE TechFee,16030,CDM,450,RC,16030,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
17110 DESTRUCT BENIGN LESION OTHER THAN SKIN TAG UP TO 14 LESION TechFee,17110,CDM,450,RC,17110,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"19020 MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP TechFee",19020,CDM,450,RC,19020,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
20102 EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK TechFee,20102,CDM,450,RC,20102,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY TechFee,20103,CDM,450,RC,20103,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
20520 REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE TechFee,20520,CDM,450,RC,20520,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
20552-Inject Trigger Point 1-2 Muscles TechFee,20552,CDM,450,RC,20552,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES TechFee,20553,CDM,450,RC,20553,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20600-Small Joint Aspirate/Inject w/o US TechFee,20600,CDM,450,RC,20600,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
20604 DRAIN/INJ JOINT/BURSA W/US TechFee,20604,CDM,450,RC,20604,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20605-L xyphoid joint injection,20605,CDM,450,RC,20605,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
20606 ARTHROCENTESIS W US GUIDANCE,20606,CDM,450,RC,20606,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20611 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,20611,CDM,450,RC,20611,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20612 ASPIRATION CYST-ER SERV PROCEDURE,20612,CDM,450,RC,20612,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST TechFee,20615,CDM,450,RC,20615,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
20670 REMOVAL OF IMPLANT; SUPERFICIAL (SEPARATE PROCEDURE) TechFee,20670,CDM,450,RC,20670,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
20950 MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME TechFee,20950,CDM,450,RC,20950,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
21315 CLOSED TX NASAL FRACTURE W/O STABILIZATION TechFee,21315,CDM,450,RC,21315,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
21320 CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION TechFee,21320,CDM,450,RC,21320,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
21450 CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITHOUT MANIPULATIO TechFee,21450,CDM,450,RC,21450,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
21451 CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION TechFee,21451,CDM,450,RC,21451,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
21480 Cloased Treatment Temporomandibular Dislocation,21480,CDM,450,RC,21480,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
21501 INCISION AND DRAINAGE DEEP ABSCESSHEMATOMA SOFT TISSUESNECKTHORAX TechFee,21501,CDM,450,RC,21501,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
23330 REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS TechFee,23330,CDM,450,RC,23330,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
23500 CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION TechFee,23500,CDM,450,RC,23500,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
23570 CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION TechFee,23570,CDM,450,RC,23570,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
23600 TREAT HUMERUS FRACTURE TechFee,23600,CDM,450,RC,23600,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
23605 CLTX PROX HUMRL FX W/MANJ W/WO SKELETAL TRACJ TechFee,23605,CDM,450,RC,23605,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES TechFee,23650,CDM,450,RC,23650,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
23655 Closed treatment of shoulder dislocation.,23655,CDM,450,RC,23655,HCPCS,outpatient,,,$850.00 ,$297.50 ,,$455.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$455.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$680.00 ,80,,,percent of total billed charges,80% of total billed charges,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$297.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$595.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$654.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$263.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$765.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$170.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$807.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.75 ,$807.50 ,
23665 CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ TechFee,23665,CDM,450,RC,23665,HCPCS,outpatient,,,$800.00 ,$280.00 ,,$428.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$428.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$640.00 ,80,,,percent of total billed charges,80% of total billed charges,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$280.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$640.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$560.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$616.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$248.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$720.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$160.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$760.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$640.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.00 ,$760.00 ,
23675 CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MANJ TechFee,23675,CDM,450,RC,23675,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
"23931 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA TechFee",21501,CDM,450,RC,23931,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24200 Fb Rem Upper Arm/Elbow-Sq TechFee,24200,CDM,450,RC,24200,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
24201 REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP Tech Fee,24201,CDM,450,RC,24201,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
24500 TREAT HUMERUS FRACTURE TechFee,24500,CDM,450,RC,24500,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
"24505 Closed treatment of humeral shaft fracture with manipulation, with or without skelatal tractio",24505,CDM,450,RC,24505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
24530 CLOSED TREAT HUMERAL FRAC W/W/OUT INTERCON EXT W/OUT MANIP TechFee,24530,CDM,450,RC,24530,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24577 CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ TechFee,24577,CDM,450,RC,24577,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24600 TREATMENT CLOSED ELBOW DISLOCATION W/O ANES TechFee,24600,CDM,450,RC,24600,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24605 TREATMENT CLOSED ELBOW DISLOCATION REQ ANES TechFee,24605,CDM,450,RC,24605,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24620 CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ TechFee,24620,CDM,450,RC,24620,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ TechFee,24640,CDM,450,RC,24640,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24650 CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION TechFee,24650,CDM,450,RC,24650,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24655 CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION TechFee,24655,CDM,450,RC,24655,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24670 ULNAR FX PROX CLOSED TX TechFee,24670,CDM,450,RC,24670,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
24675 CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ TechFee,24675,CDM,450,RC,24675,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
24999 UNLISTED PROCEDURE HUMERUS/ELBOW TechFee,24999,CDM,450,RC,24999,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
"25248 EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST TechFee",25248,CDM,450,RC,25248,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
25500 TREAT FRACTURE OF RADIUS TechFee,25500,CDM,450,RC,25500,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25505 CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION TechFee,25505,CDM,450,RC,25505,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25530 CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION TechFee,25530,CDM,450,RC,25530,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25535 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITH MANIPULATION TechFee,25535,CDM,450,RC,25535,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25560 CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN TechFee,25560,CDM,450,RC,25560,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25565- Closed treatment radial and ulnar shaft fracture: with manipulation,25565,CDM,450,RC,25565,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ TechFee,25600,CDM,450,RC,25600,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25605 CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF TechFee,25605,CDM,450,RC,25605,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25622 TREAT WRIST BONE FRACTURE TechFee,25622,CDM,450,RC,25622,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25630 TREAT WRIST BONE FRACTURE TechFee,25630,CDM,450,RC,25630,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25650 CLOSED TREATMENT ULNAR STYLOID FRACTURE TechFee,25650,CDM,450,RC,25650,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25660 CLOSED TREAT RADIO/INTERCARP DISLOC 1-MORE BONES W/MANIP TechFee,25660,CDM,450,RC,25660,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
25690 CLOSED TX LUNATE DISLOCATION W/MANIPULATION TechFee,25690,CDM,450,RC,25690,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26010 DRAINAGE FINGER ABSCESS SIMPLE TechFee,26010,CDM,450,RC,26010,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
26011 DRAINAGE FINGER ABSCESS COMPLICATED TechFee,26011,CDM,450,RC,26011,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
26115 PROF EXC HAND LES SC>1.5C TechFee,26115,CDM,450,RC,26115,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
26123 FASCIECTOMY PALM ONLY TechFee,26123,CDM,450,RC,26123,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26236 PARTIAL EXCISION DISTAL PHALANX FINGER TechFee,26236,CDM,450,RC,26236,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
26350 RPR/ADVMNT FLXR TDN N/Z/2 W/O FR GRAFT EA TENDON TechFee,26350,CDM,450,RC,26350,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
26418 REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH,26418,CDM,450,RC,26418,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
26600 CLTX METACARPAL FX W/O MANIPULATION EACH BONE TechFee,26600,CDM,450,RC,26600,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
26605 CLTX METACARPAL FX W/MANIPULATION EACH BONE TechFee,26605,CDM,450,RC,26605,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26641 CLTX CARPO/METACARPAL DISLOCATION THUMB W/MANJ TechFee,26641,CDM,450,RC,26641,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26670 CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES TechFee,26670,CDM,450,RC,26670,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
26700 CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES TechFee,26700,CDM,450,RC,26700,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26705 CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES TechFee,26705,CDM,450,RC,26705,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
26720 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA TechFee,26720,CDM,450,RC,26720,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
"26725 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb",26725,CDM,450,RC,26725,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26727 FIXATION PERCUT FINGER TechFee,26727,CDM,450,RC,26727,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"26742 CLOSED TREATMENT OF ARTICULAR FRACTURE OF METACARPO/INTER PHALANGEAL JOINT; W/ MANIPULATION, E",26742,CDM,450,RC,26742,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26750 CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA TechFee,26750,CDM,450,RC,26750,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26755 CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA TechFee,26755,CDM,450,RC,26755,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
26765 OPEN TX DISTAL PHALANGEAL FRACTURE EACH TechFee,26765,CDM,450,RC,26765,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26770 CLTX IPHAL JT DISLC W/MANJ W/O ANES TechFee,26770,CDM,450,RC,26770,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26775 CLTX IPHAL JT DISLC W/MANJ REQ ANES TechFee,26775,CDM,450,RC,26775,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26951 AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR TechFee,26951,CDM,450,RC,26951,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26952 AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP TechFee,26952,CDM,450,RC,26952,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"26989 UNLISTED PROCEDURE, HANDS OR FINGERS TechFee",26989,CDM,450,RC,26989,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
27220 CLOSED TX ACETABULUM W/O TechFee,27220,CDM,450,RC,27220,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
27222 CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ TechFee,27222,CDM,450,RC,27222,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27230 TREATMENT CLOSED FEMORAL FRACT-ER SERV,27230,CDM,450,RC,27230,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27232 TREATMENT CLOSED FEMORAL FRAC-ER SERV PR,27232,CDM,450,RC,27232,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
27238 TREATMENT CL INT FEMORAL FRAC-ER SERV PR,27238,CDM,450,RC,27238,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27244 TRMT INTERTRONCHANTERIC PERITROCHANTERIC SUBTROCH FEMORAL FX TechFee,27244,CDM,450,RC,27244,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27246 CLTX GREATER TROCHANTERIC FX W/O MANJ TechFee,27246,CDM,450,RC,27246,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"27250 Closed treatment hip dislocation, traumatic:w/o anes",27250,CDM,450,RC,27250,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"27252 Closed treatment hip dislocation, traumatic:w/anes",27252,CDM,450,RC,27252,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27256 TREATMENT SP HIP DISLOCATION-ER SERV PRO,72756,CDM,450,RC,27256,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"27257 TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHO Tech",27257,CDM,450,RC,27257,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
27265  Closed treatment of post hip arthroplasty dislocation,27265,CDM,450,RC,27265,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
27266 Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesi,27266,CDM,450,RC,27266,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
"27500 CLOSED TREAT FEMORAL SHAFT FRACTURE, WITHOUT MANIPULATION TechFee",27500,CDM,450,RC,27500,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27502 CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ TechFee,27502,CDM,450,RC,27502,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27510 ED TREATMENT OF THIGH FRACTURE TechFee,27510,CDM,450,RC,27510,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27520 CLSD TX PATELLAR FX W/O M TechFee,27520,CDM,450,RC,27520,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27550 CLOSED TX KNEE DISLOCATION W/O ANESTHESIA TechFee,27550,CDM,450,RC,27550,HCPCS,outpatient,,,$169.00 ,$59.15 ,,$90.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.20 ,80,,,percent of total billed charges,80% of total billed charges,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$152.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.96 ,$160.55 ,
27552 TREATMENT CL KNEE DISLOCATIO-ER SERV PRO,27552,CDM,450,RC,27552,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
27562 CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA TechFee,27562,CDM,450,RC,27562,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
27599 UNLISTED PROCEDURE FEMUR/KNEE TechFee,27599,CDM,450,RC,27599,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"27650 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; TechFee",27650,CDM,450,RC,27650,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27750 CLTX TIBIAL SHAFT FX W/O MANIPULATION TechFee,27750,CDM,450,RC,27750,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"27752 Closed treatment of tibial shaft fracture (w/ or w/o fibular fracture); w/ manipulation, w/ or",27752,CDM,450,RC,27752,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27760 CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION TechFee,27760,CDM,450,RC,27760,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27762 CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ TechFee,27762,CDM,450,RC,27762,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27768 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH MANIPULATION. TechFee,27768,CDM,450,RC,27768,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27786 CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ TechFee,27786,CDM,450,RC,27786,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"27808 CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL TechFee",27808,CDM,450,RC,27808,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27810 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ TechFee,27810,CDM,450,RC,27810,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27816 CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION TechFee,27816,CDM,450,RC,27816,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27818 Closed treatment of trimalleolar ankle fracture TechFee,27818,CDM,450,RC,27818,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27825 CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ TechFee,27825,CDM,450,RC,27825,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
27840 CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA TechFee,27840,CDM,450,RC,27840,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
27842 CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ TechFee,27842,CDM,450,RC,27842,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
28192 REMOVAL FOREIGN BODY FOOT DEEP TechFee,28192,CDM,450,RC,28192,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28193 Fb Removal Foot Comp TechFee,28193,CDM,450,RC,28193,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
28400 CALCANEAL FX TechFee,28400,CDM,450,RC,28400,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
28435 CLOSED TX TALUS FRACTURE W/MANIPULATION TechFee,28435,CDM,450,RC,28435,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28470 CLOSED TX METATARSAL FRACTURE W/O MANIPULATION TechFee,28470,CDM,450,RC,28470,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"28475 CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, EACH TechFee",28475,CDM,450,RC,28475,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28490 CLTX FX GRT TOE PHLX/PHLG W/O MANJ TechFee,28490,CDM,450,RC,28490,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
28495 CLTX FX GRT TOE PHLX/PHLG W/MANJ TechFee,28495,CDM,450,RC,28495,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ TechFee,28510,CDM,450,RC,28510,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TechFee,28515,CDM,450,RC,28515,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
28540 Reduce Disloc Tarsal TechFee,28540,CDM,450,RC,28540,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
"28545 CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; REQUIRING ANESTHES Tech",28545,CDM,450,RC,28545,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28600 Red Dl Tarsometatar TechFee,28600,CDM,450,RC,28600,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28630 CLTX METATARSOPHLNGL JT DISLC W/O ANES TechFee,28630,CDM,450,RC,28630,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28660 CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES TechFee,28660,CDM,450,RC,28660,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
29049 APPLICATION CAST FIGURE-OF-8 TechFee,29049,CDM,450,RC,29049,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29075 APPLICATION CAST ELBOW FINGER SHORT ARM TechFee,29075,CDM,450,RC,29075,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
29085 CAST HAND/LOWER FOREARMT TechFee,29085,CDM,450,RC,29085,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
29105 ER LONG ARM SPLINT (SHOULDER TO HAND),29105,CDM,450,RC,29105,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC TechFee,29125,CDM,450,RC,29125,HCPCS,outpatient,,,$50.00 ,$17.50 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,$47.50 ,
29126 APPLICATION SHORT ARM SPLINT DYNAMIC TechFee,29126,CDM,450,RC,29126,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29130 APPLICATION FINGER SPLINT STATIC,29130,CDM,450,RC,29130,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29131 APPLICATION FINGER SPLINT DYNAMIC TechFee,29131,CDM,450,RC,29131,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29240 STRAPPING SHOULDER TechFee,29240,CDM,450,RC,29240,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
29280 STRAPPING HAND/FINGER TechFee,29280,CDM,450,RC,29280,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29345 APPLICATION LONG LEG CAST THIGH-TOE TechFee,29345,CDM,450,RC,29345,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29405 APPLICATION SHORT LEG CAST BELOW KNEE-TOE TechFee,29405,CDM,450,RC,29405,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
29425 APPLY SHORT LEG CAST TechFee,29425,CDM,450,RC,29425,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
29505 APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES TechFee,29505,CDM,450,RC,29505,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
29515 APPLICATION SHORT LEG SPLINT CALF FOOT TechFee,29515,CDM,450,RC,29515,HCPCS,outpatient,,,$110.00 ,$38.50 ,,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.45 ,$104.50 ,
29530 STRAPPING KNEE TechFee,29530,CDM,450,RC,29530,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29540 STRAPPING ANKLE &/FOOT TechFee,29540,CDM,450,RC,29540,HCPCS,outpatient,,,$65.00 ,$22.75 ,,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$58.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.68 ,$61.75 ,
29550 STRAPPING TOES TechFee,29550,CDM,450,RC,29550,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
29580 STRAPPING UNNA BOOT TechFee,29580,CDM,450,RC,29580,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29705 REMOVAL/BIVALVING FULL ARM/FULL LEG CAST TechFee,29705,CDM,450,RC,29705,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
29799 UNLISTED PROCEDURE CASTING/STRAPPING TechFee,29799,CDM,450,RC,29799,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
30300 REMOVAL NASAL FOREIGN BODY-ER SERV PROCE,30300,CDM,450,RC,30300,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.15 ,$161.50 ,
30310 REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES TechFee,30310,CDM,450,RC,30310,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"30903 CONTROL ANT. NASAL HEMOR,COMP- ER SERV P",30903,CDM,450,RC,30903,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
30905 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST TechFee,30905,CDM,450,RC,30905,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
30906 CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ TechFee,30906,CDM,450,RC,30906,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
31238 Nasal Endoscopy,31238,CDM,450,RC,31238,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
31500 INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE TechFee,31500,CDM,450,RC,31500,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
31502 INTRO PROC ON LARYNX TechFee,31502,CDM,450,RC,31502,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31505 DIAGNOSTIC LARYNGOSCOPY TechFee,31505,CDM,450,RC,31505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31525 LARYNGOSCOPY W/WO TRACHEOSCOPY DX EXCEPT NEWBORN TechFee,31525,CDM,450,RC,31525,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
31530 Laryngoscopy w Fb Removal Tech Fee,31530,CDM,450,RC,31530,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
31575 LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,31575,CDM,450,RC,31575,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31603 TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL TechFee,31603,CDM,450,RC,31603,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
31605 TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE TechFee,31505,CDM,450,RC,31605,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
32110 THORCOM CTRL TRAUMTC HEMRRG&/RPR LNG TEAR TechFee,32110,CDM,361,RC,32110,HCPCS,outpatient,,,"$4,990.00 ","$1,746.50 ",,"$2,674.64 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,674.64 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,992.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,577.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,746.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,992.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,493.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,493.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,842.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,562.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$973.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,546.90 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,491.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,001.99 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,740.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,992.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$992.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,640.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,742.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,001.99 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,241.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$973.05 ,"$4,740.50 ",
32550 ED INSERT PLEURAL CATH WITH CUFF TechFee,32550,CDM,450,RC,32550,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
32551 TUBE THORACOSTOMY INCLUDES WATER SEAL TechFee,32551,CDM,450,RC,32551,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
32554 THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING TechFee,32554,CDM,450,RC,32554,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
32555 THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING TechFee,32555,CDM,450,RC,32555,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
"32556 ED Tech Fee Pleural drainage, percut, w insert of indwelling cath; w/o image guide",32556,CDM,450,RC,32556,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.15 ,$161.50 ,
36000 INTRODUCTION NEEDLE/INTRACATHETER VEIN TechFee,36000,CDM,450,RC,36000,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36410 VNPNXR 3 YEARS/> PHYS/QHP SKILL TechFee,36410,CDM,450,RC,36410,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36420 VENIPUNCTURE CUTDOWN UNDER AGE 1 YR TechFee,36420,CDM,450,RC,36420,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> TechFee,36556,CDM,450,RC,36556,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
36557 INSERT TUNNELED CVC W/O SUBQ PORT/PMP AGE <5 YR,36557,CDM,450,RC,36557,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
36558 INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> TechFee,36558,CDM,450,RC,36558,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36569 INSERTION PICC W/O IMG GDN 5 YR/> TechFee,36569,CDM,370,RC,36569,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"36573 INSERTION OF PICC, W/O SUBCUTANEOUS PORT OR PUMP TechFee",36573,CDM,450,RC,36573,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36589 RMVL TUN CVC W/O SUBQ PORT/PMP TechFee,36589,CDM,450,RC,36589,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
36591 Blood draw or  Accessing charge from IMPLANTABLE PORT I.E. PORTACATH,17250,CDM,450,RC,17250,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
36592 BLD DRAW per RN Central line,36592,CDM,450,RC,36592,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
36600 ARTERIAL PUNCTURE (BLOOD GAS),36600,CDM,450,RC,36600,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
36620 ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ TechFee,36620,CDM,450,RC,36620,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36680 PLACEMENT NEEDLE INTRAOSSEOUS INFUSION TechFee,36680,CDM,450,RC,36680,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
37195 ED TECH TPA GIVEN IV,37195,CDM,450,RC,37195,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
38220 Bone Marrow Aspiration Bilat TechFee,38220,CDM,450,RC,38220,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
38221 Bone Marrow Biopsy Bilat TechFee,38221,CDM,450,RC,38221,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
38505 BX/EXC LYMPH NODE NEEDLE SUPERFICIAL TechFee,38505,CDM,450,RC,38505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
40650 REPAIR LIP FT; VERMILION ONLY,40650,CDM,450,RC,40650,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL TechFee,40800,CDM,450,RC,40800,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
40830 CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/< TechFee,40830,CDM,450,RC,40830,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
40831 CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL TechFee,40831,CDM,450,RC,40831,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41250 EP LACERAT 2.5 CM/<; FLR-MOUTH/ANT 2/3,41250,CDM,450,RC,41250,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41251 REPAIR OF LACERATION 2.5 CM OR LESS TechFee,41251,CDM,361,RC,41251,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41800 Drainage of Abscess Cyst Hematoma from Dentoalveolar Structures,41800,CDM,450,RC,41800,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
41899 UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES,41899,CDM,450,RC,41899,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
42000 DRAINAGE ABSCESS PALATE UVULA,42000,CDM,450,RC,42000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
42700 ED Tech Fee I&D Abscess; Peritonsillar,42700,CDM,450,RC,42700,HCPCS,outpatient,,,$168.00 ,$58.80 ,,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$151.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.76 ,$159.60 ,
42809 REMOVAL FOREIGN BODY PHARYNX TechFee,42809,CDM,450,RC,42809,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
42960 CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE TechFee,42960,CDM,450,RC,42960,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"42999 Throat, adenoids, or tonsils procedure",42999,CDM,450,RC,42999,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
43752 NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE TechFee,43752,CDM,450,RC,43752,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43753 GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE TechFee,43753,CDM,450,RC,43753,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43754 GASTRIC INTUBAT DX W/ASPIRATION SINGLE SPECIMEN TechFee,43754,CDM,450,RC,43754,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43762 PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC TechFee,43762,CDM,450,RC,43762,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43763 PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC TechFee,43763,CDM,450,RC,43763,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
45900 REDUCTION OF RECTAL PROLAPSE TechFee,45900,CDM,450,RC,45900,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
45915 RMVL FECAL IMPACTION/FB SPX UNDER ANES TechFee,45915,CDM,450,RC,45915,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
46040 I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX TechFee,46040,CDM,450,RC,46040,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46050 I&D PERIANAL ABSCESS SUPERFICIAL TechFee,46050,CDM,450,RC,46050,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46083 INCISION THROMBOSED HEMORRHOID EXTERNAL TechFee,46083,CDM,450,RC,46083,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46320 ED REMOVAL OF HEMORRHOID CLOT TechFee,46320,CDM,450,RC,46320,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
46600 Diagnostic Anoscopy TechFee,46600,CDM,450,RC,46600,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
"49082 INCISION PROC ON THE ABDM, PERITONEUM, AND OMENTUM TechFee",49082,CDM,450,RC,49082,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
49083 ED ABDOMINAL PARACENTESIS W GUIDE CHARGE,49083,CDM,450,RC,49083,HCPCS,outpatient,,,"$1,500.00 ",$525.00 ,,$804.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$804.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$525.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,050.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,050.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,155.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$465.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,350.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$301.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,425.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$301.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$292.50 ,"$1,425.00 ",
49084 PERITONEAL LAVAGE W/WO IMAGING GUIDANCE,49084,CDM,450,RC,49084,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"49440 INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CON TechFee",49440,CDM,450,RC,49440,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"49450 REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER F TechFee",49450,CDM,450,RC,49450,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
49451 REPLACE DUOD/JEJ TUBE PERC TechFee,49451,CDM,450,RC,49451,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
"51040 CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE Tech",51040,CDM,450,RC,51040,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
51102 Drain Bl w Cath Insertion TechFee,51102,CDM,450,RC,51102,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51700 Bladder irrigation and/or instillation,51700,CDM,450,RC,51700,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51701 ER TECH STRAIGHT CATH,51701,CDM,450,RC,51701,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
51702 INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE TechFee,51702,CDM,450,RC,51702,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
51703 INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED TechFee,51703,CDM,450,RC,51703,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51705 CHANGE CYSTOSTOMY TUBE SIMPLE TechFee,51705,CDM,450,RC,51705,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"51798 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON- TechFee",51798,CDM,450,RC,51798,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
52005 CYSTOURETHROSCOPY W/URETERAL CATH,52005,CDM,450,RC,52005,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
54220 IRRIGATE CORPORA CAVERNOSA FOR PRIAPISM,54220,CDM,450,RC,54220,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
54700 ED INCISION AND DRAINAGE EPIDIDYMIS TSTIS&/SCROTAL SPACE TechFee,54700,CDM,450,RC,54700,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
55100 Drainage of scrotal wall abscess TechFee,55100,CDM,450,RC,55100,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
56405 I&D VULVA/PERINEAL ABSCESS TechFee,56405,CDM,450,RC,56405,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
56420- I&D Bartholin gland abscess,56420,CDM,450,RC,56420,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
57200 COLPORRHAPHY SUTURE INJURY VAGINA TechFee,57200,CDM,450,RC,57200,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
58301 REMOVAL INTRAUTERINE DEVICE IUD TechFee,58301,CDM,450,RC,58301,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
59409 VAGINAL DELIVERY ONLY TechFee,59409,CDM,450,RC,59409,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
59414 DELIVERY PLACENTA SEPARATE PROCEDURE TechFee,59414,CDM,450,RC,59414,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
62270 SMALL JOINT ASPIRATION,62270,CDM,450,RC,62270,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH TechFee",62273,CDM,450,RC,62273,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"64400 INJECTION, ANESTHETIC AGENT TechFee",64400,CDM,450,RC,64400,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.79 ,$115.90 ,
64405 INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV TechFee,64405,CDM,450,RC,64405,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.79 ,$115.90 ,
64415 NBlk Inj Brachial Plexus TechFee,64415,CDM,450,RC,64415,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"64450 ED Tech Inject Anesthetic Agent, Other Peripheral Nerve or Branch",64450,CDM,450,RC,64450,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
64505 INJECTION ANES AGENT SPHENOPALATINE GANGLION TechFee,64505,CDM,450,RC,64505,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
64999 UNLISTED PROCEDURE NERVOUS SYSTEM TechFee,64999,CDM,450,RC,64999,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
65205 REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL TechFee,65205,CDM,450,RC,65205,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
65210 RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR TechFee,65210,CDM,450,RC,65210,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
65220 RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP TechFee,65220,CDM,450,RC,65220,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
65222 RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP TechFee,65222,CDM,450,RC,65222,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
65235 RMVL FB INTRAOCULAR ANT CHAMBER EYE/LENS TechFee,65235,CDM,450,RC,65235,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
65435 Removal/Destruction procedures of the cornea,65435,CDM,450,RC,65435,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
67700 ED DRAINAGE OF EYELID ABSCESS TechFee,67700,CDM,450,RC,67700,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
67800 EXCISION CHALAZION SINGLE TechFee,67800,CDM,450,RC,67800,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
67938 REMOVAL EMBEDDED FOREIGN BODY EYELID TechFee,67938,CDM,450,RC,67938,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
69000 DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPL,69000,CDM,450,RC,69000,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69020 DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS,69020,CDM,450,RC,69020,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69200 RMVL FB XTRNL AUDITORY CANAL W/O ANES TechFee,69200,CDM,450,RC,69200,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
69205 RMVL FB XTRNL AUDITORY CANAL ANES TechFee,69205,CDM,450,RC,69205,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"69209 - Removal impacted cerumen using irrigation/lavage, unilateral Tech Fee",69209,CDM,450,RC,69209,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69210 REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT TechFee,69210,CDM,450,RC,69210,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
90460  IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX TechFee,90460,CDM,450,RC,90460,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
90471  IM ADM PRQ ID SUBQ IM NJXS 1 VACCINE TechFee,90471,CDM,771,RC,90471,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
90472  IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE TechFee,90472,CDM,450,RC,90472,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
92950 CARDIOPULMONARY RESUSCITATION TechFee,92950,CDM,450,RC,92950,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
92953 Temporary External Pacing TechFee,92953,CDM,450,RC,92953,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
92960 CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL TechFee,92960,CDM,450,RC,92960,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"96360 INTRAVENOUS INFUSION, HYDRATION TechFee",96360,CDM,450,RC,96360,HCPCS,outpatient,,,$322.36 ,$112.83 ,,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$290.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.86 ,$306.24 ,
"96361 INTRAVENOUS INFUSION, HYDRATION TechFee",96361,CDM,450,RC,96361,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"96365 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS TechFee",96365,CDM,450,RC,96365,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"96366 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS TechFee",96366,CDM,450,RC,96366,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS TechFee",96367,CDM,450,RC,96367,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"96368 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS TechFee",96368,CDM,450,RC,96368,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96372 IM SC Injection Each TechFee,96372,CDM,450,RC,96372,HCPCS,outpatient,,,$138.65 ,$48.53 ,,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.04 ,$131.72 ,
"96374 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION TechFee",96374,CDM,450,RC,96374,HCPCS,outpatient,,,$153.15 ,$53.60 ,,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$47.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$137.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.86 ,$145.49 ,
"96375 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION ED",96375,CDM,450,RC,96375,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"96376 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION TechFee",96376,CDM,450,RC,96376,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96523 OTHER INJECTION AND INFUSION SERVICES TechFee,96523,CDM,450,RC,96523,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
96523- Port Flush,96523,CDM,760,RC,96523,HCPCS,outpatient,,,$129.00 ,$45.15 ,,$69.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.75 ,75,,,percent of total billed charges,75% of total billed charges,$96.75 ,75,,,percent of total billed charges,75% of total billed charges,$96.75 ,75,,,percent of total billed charges,75% of total billed charges,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.20 ,80,,,percent of total billed charges,80% of total billed charges,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$99.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$116.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.16 ,$122.55 ,
97597 DEBRIDEMENT OPEN WOUND <=20 SQ CM TechFee,97597,CDM,450,RC,97597,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99151 MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,99151,CDM,450,RC,99151,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99152 MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,99152,CDM,450,RC,99152,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99153 MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,99153,CDM,450,RC,99153,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99155 MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS TechFee,99155,CDM,450,RC,99155,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99156 MOD SED OTH PHYS/QHP 5/>YRS TechFee,99156,CDM,450,RC,99156,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99157 MOD SED OTHER PHYS/QHP EA TechFee,99157,CDM,450,RC,99157,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
G0009  Admin pneumococcal vaccine,264620,CDM,771,RC,G0009,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
G0260 Inj for sacroiliac jt anesth Tech Fee,G0260,CDM,450,RC,G0260,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
G0390 TRAUMA RESPONS W/HOSP CRITI TechFee,G0390,CDM,450,RC,G0390,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
G0396 Alcohol Subs Interv 15to30 Min TechFee,G0396,CDM,361,RC,G0396,HCPCS,outpatient,,,$107.00 ,$37.45 ,,$57.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.25 ,75,,,percent of total billed charges,75% of total billed charges,$80.25 ,75,,,percent of total billed charges,75% of total billed charges,$80.25 ,75,,,percent of total billed charges,75% of total billed charges,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.60 ,80,,,percent of total billed charges,80% of total billed charges,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$96.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$101.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.87 ,$101.65 ,
SHOULDER IMMOB,28891,CDM,270,RC,,HCPCS,outpatient,,,$29.00 ,$10.15 ,,$15.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.75 ,75,,,percent of total billed charges,75% of total billed charges,$21.75 ,75,,,percent of total billed charges,75% of total billed charges,$21.75 ,75,,,percent of total billed charges,75% of total billed charges,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.20 ,80,,,percent of total billed charges,80% of total billed charges,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$26.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.66 ,$27.55 ,
92507 SPEECH TREATMENT Charge,10526272,CDM,440,RC,92507,HCPCS,outpatient,,,$290.00 ,$101.50 ,,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$223.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$261.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$275.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.55 ,$275.50 ,
"99224 Subsequent Observation Visit, Low",99224,CDM,983,RC,99224,HCPCS,outpatient,,,$210.00 ,$73.50 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
Collection and interpretation of physiologic data digitally store and/or transmitted by the patient,99091,CDM,510,RC,99091,HCPCS,outpatient,,,$262.85 ,$92.00 ,,$140.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$140.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$197.14 ,75,,,percent of total billed charges,75% of total billed charges,$197.14 ,75,,,percent of total billed charges,75% of total billed charges,$197.14 ,75,,,percent of total billed charges,75% of total billed charges,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$210.28 ,80,,,percent of total billed charges,80% of total billed charges,$83.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$210.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$236.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$249.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$223.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.26 ,$249.71 ,
"G0444 Depression Screening, 15 minutes",G0444,CDM,510,RC,G0444,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
G0447 Obesity Counseling; 15 min,G0447,CDM,510,RC,G0447,HCPCS,outpatient,,,$189.00 ,$66.15 ,,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$170.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.86 ,$179.55 ,
Office Outpatient visit 15 mins,99213,CDM,982,RC,99213,HCPCS,outpatient,,,$215.00 ,$75.25 ,,$40.70 ,100,,,fee schedule,100% Amerigroup fee schedule,$40.70 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$44.36 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$40.70 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.92 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.92 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$40.70 ,$44.36 ,
Office Visit Established 25 mins,992141,CDM,982,RC,99214,HCPCS,outpatient,,,$312.00 ,$109.20 ,,$62.71 ,100,,,fee schedule,100% Amerigroup fee schedule,$62.71 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.35 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.71 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$64.59 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$64.59 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$62.71 ,$68.35 ,
.GTT 1 HR,153271,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.GTT 2 HR,153272,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.GTT 3 HR,153273,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.GTT 3 HR OB,153274,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.GTT 4 HR,153275,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.GTT 5 HR,153276,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
.Glucose Fasting,151072,CDM,301,RC,82947,HCPCS,outpatient,,,$49.34 ,$17.27 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.47 ,80,,,percent of total billed charges,80% of total billed charges,$15.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$46.87 ,
.Manual Differential (JDHS),LAB0005,CDM,300,RC,85032,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,$7.03 ,
.Morphology (JDHS),LAB0005,CDM,300,RC,85032,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,$7.03 ,
.RPR LC,15181,CDM,300,RC,86592,HCPCS,outpatient,,,$28.00 ,$9.80 ,,$3.76 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.76 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.00 ,75,,,percent of total billed charges,75% of total billed charges,$14.00 ,75,,,percent of total billed charges,75% of total billed charges,$14.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$22.40 ,80,,,percent of total billed charges,80% of total billed charges,$8.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.88 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$22.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.05 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.74 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.79 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$23.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.76 ,$26.60 ,
".SARS-CoV-2, NAA 2 DAY TAT LC",30242,CDM,300,RC,87426,HCPCS,outpatient,,,$82.23 ,$28.78 ,,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$65.78 ,80,,,percent of total billed charges,80% of total billed charges,$26.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.33 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$74.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$78.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.00 ,$78.12 ,
"2019 Novel Coronavirus (CoVID-19), NAA LC",,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
88112 AP Bill Cytopath cell enhance tech,16255,CDM,311,RC,88112,HCPCS,outpatient,,,$127.00 ,$44.45 ,,$111.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$111.50 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.19 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$114.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$138.05 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$120.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.31 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.37 ,$138.05 ,
88300 AP Bill Surg Level I,88300,CDM,312,RC,88300,HCPCS,outpatient,,,$52.00 ,$18.20 ,,$15.02 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.02 ,100,,,fee schedule,100% Amerigroup fee schedule,$26.00 ,75,,,percent of total billed charges,75% of total billed charges,$26.00 ,75,,,percent of total billed charges,75% of total billed charges,$26.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.60 ,80,,,percent of total billed charges,80% of total billed charges,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.40 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$49.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.13 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.95 ,$49.40 ,
88302 AP Bill Surg Level II,88302,CDM,312,RC,88302,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$36.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$36.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.21 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.41 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.93 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.41 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.68 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.41 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$22.32 ,$68.40 ,
88304 AP Bill Surg Level III,88304,CDM,312,RC,88304,HCPCS,outpatient,,,$94.00 ,$32.90 ,,$31.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$75.20 ,80,,,percent of total billed charges,80% of total billed charges,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.11 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.25 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$29.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$84.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$89.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.60 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.25 ,$89.30 ,
88305 AP Bill Surg Level IV,16161,CDM,312,RC,88305,HCPCS,outpatient,,,$212.00 ,$74.20 ,,$69.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$69.17 ,100,,,fee schedule,100% Amerigroup fee schedule,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.00 ,75,,,percent of total billed charges,75% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges,$67.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.52 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$190.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$201.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$180.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$27.16 ,$201.40 ,
88312 AP Bill Special Stain Group 1 Microorganisms I&R,16164,CDM,312,RC,88312,HCPCS,outpatient,,,$127.00 ,$44.45 ,,$45.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$45.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.84 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$114.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.79 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$120.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.44 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.84 ,$120.65 ,
88342 AP Bill Surg IPX (First Antibody),16254,CDM,312,RC,88342,HCPCS,outpatient,,,$260.00 ,$91.00 ,,$75.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$75.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$130.00 ,75,,,percent of total billed charges,75% of total billed charges,$130.00 ,75,,,percent of total billed charges,75% of total billed charges,$130.00 ,75,,,percent of total billed charges,75% of total billed charges,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.00 ,80,,,percent of total billed charges,80% of total billed charges,$82.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.27 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$200.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.29 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.64 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$80.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$234.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$247.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.29 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.62 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$221.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.29 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$32.64 ,$247.00 ,
"ACTH, Plasma LC",8447627,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"AFP, Serum, Tumor Marker LC",8446713,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
ANA LC,8447905,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
ANA w/ Reflex IFA LC,15040,CDM,300,RC,86038,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$15.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.96 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.20 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.09 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.76 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.50 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.66 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.09 ,$161.50 ,
ANA w/Reflex EIA LC,150401,CDM,300,RC,86038,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$15.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$85.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.96 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.20 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.09 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.76 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.50 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.66 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.50 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.09 ,$161.50 ,
Acetaminophen Level,15018,CDM,300,RC,80307,HCPCS,outpatient,,,$93.35 ,$32.67 ,,$50.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$74.68 ,80,,,percent of total billed charges,80% of total billed charges,$29.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$74.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$84.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$88.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.52 ,$88.68 ,
Acute Hepatitis LC,9696438,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Alanine Aminotransferase TC,15187,CDM,300,RC,84460,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.30 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.30 ,$8.26 ,
Albumin Level,15028,CDM,300,RC,82040,HCPCS,outpatient,,,$62.00 ,$21.70 ,,$3.80 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.80 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$49.60 ,80,,,percent of total billed charges,80% of total billed charges,$19.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.80 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.00 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.95 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$58.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.69 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.73 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.62 ,$58.90 ,
"Albumin, Body Fluid LC",8453198,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Albumin/Creatinine Ratio,Urine LC",160611,CDM,300,RC,82043,HCPCS,outpatient,,,$54.34 ,$19.02 ,,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$43.47 ,80,,,percent of total billed charges,80% of total billed charges,$17.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.78 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$51.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.43 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.78 ,$51.62 ,
Alcohol Level,15029,CDM,301,RC,80320,HCPCS,outpatient,,,$18.05 ,$6.32 ,,$9.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.03 ,75,,,percent of total billed charges,75% of total billed charges,$9.03 ,75,,,percent of total billed charges,75% of total billed charges,$9.03 ,75,,,percent of total billed charges,75% of total billed charges,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.44 ,80,,,percent of total billed charges,80% of total billed charges,$5.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.27 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.59 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.67 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$17.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.00 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$15.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.60 ,$17.67 ,
Aldolase LC,11110,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Aldosterone/Renin Ratio LC,LAB0029,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Alkaline Phosphatase,15031,CDM,300,RC,84075,HCPCS,outpatient,,,$32.00 ,$11.20 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$25.60 ,80,,,percent of total billed charges,80% of total billed charges,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$30.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$30.40 ,
Ammonia Level,15036,CDM,301,RC,82140,HCPCS,outpatient,,,$65.78 ,$23.02 ,,$13.06 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.06 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.62 ,80,,,percent of total billed charges,80% of total billed charges,$20.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.06 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.57 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.17 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.69 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.81 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.44 ,$62.49 ,
Amylase Level,15039,CDM,301,RC,82150,HCPCS,outpatient,,,$192.34 ,$67.32 ,,$8.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$96.17 ,75,,,percent of total billed charges,75% of total billed charges,$96.17 ,75,,,percent of total billed charges,75% of total billed charges,$96.17 ,75,,,percent of total billed charges,75% of total billed charges,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$153.87 ,80,,,percent of total billed charges,80% of total billed charges,$60.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.56 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$153.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.15 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.48 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$173.11 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$182.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.31 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$144.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.39 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$163.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.48 ,$182.72 ,
Anemia Panel,12345,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Anti-CCP Ab, IgG + IgA (RDL) LC",9533809,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Antineutrophil Cytoplasmic Ab LC,8447803,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Antiparietal Cell Antibody LC,9275142,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Antistreptolysin O Ab LC,2,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Aspartate Aminotransferase,15186,CDM,301,RC,84450,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$8.26 ,
Auto Diff,150551,CDM,305,RC,85025,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.77 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$12.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.97 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.77 ,$12.70 ,
B-Type Natriuretic Peptide,28888,CDM,300,RC,83880,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.69 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.26 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$20.58 ,$61.82 ,
"B. pertussis Abs, IgA, IgG, IgM LC",10716966,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
BMP (8) LC,160361,CDM,301,RC,80048,HCPCS,outpatient,,,$88.55 ,$30.99 ,,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$70.84 ,80,,,percent of total billed charges,80% of total billed charges,$28.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.46 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$84.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.46 ,$84.12 ,
BUN and Creatinine,160614,CDM,300,RC,82043,HCPCS,outpatient,,,$76.00 ,$26.60 ,,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$60.80 ,80,,,percent of total billed charges,80% of total billed charges,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.78 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.43 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.78 ,$72.20 ,
Basic Metabolic Panel,160366,CDM,301,RC,80048,HCPCS,outpatient,,,$88.55 ,$30.99 ,,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$70.84 ,80,,,percent of total billed charges,80% of total billed charges,$28.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.46 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$84.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.46 ,$84.12 ,
Basic Metabolic Panel,16036,CDM,300,RC,80048,HCPCS,outpatient,,,$123.84 ,$43.34 ,,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$61.92 ,75,,,percent of total billed charges,75% of total billed charges,$61.92 ,75,,,percent of total billed charges,75% of total billed charges,$61.92 ,75,,,percent of total billed charges,75% of total billed charges,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$99.07 ,80,,,percent of total billed charges,80% of total billed charges,$39.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$95.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.46 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$111.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$117.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$92.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$92.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$92.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$105.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.46 ,$117.65 ,
Beta Strep Gp A Culture LC,15809,CDM,300,RC,87070,HCPCS,outpatient,,,$30.00 ,$10.50 ,,$11.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.79 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.00 ,80,,,percent of total billed charges,80% of total billed charges,$9.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.83 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.62 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.15 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.62 ,$28.50 ,
Beta hCG Quantitative,15782,CDM,300,RC,84702,HCPCS,outpatient,,,$160.88 ,$56.31 ,,$8.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$80.44 ,75,,,percent of total billed charges,75% of total billed charges,$80.44 ,75,,,percent of total billed charges,75% of total billed charges,$80.44 ,75,,,percent of total billed charges,75% of total billed charges,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$128.70 ,80,,,percent of total billed charges,80% of total billed charges,$50.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.47 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.07 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.05 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$144.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$152.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.23 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.07 ,$152.84 ,
"Beta-2 Microglobulin, Serum LC",8447664,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Bilirubin Direct,9,CDM,300,RC,82248,HCPCS,outpatient,,,$7.00 ,$2.45 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.60 ,80,,,percent of total billed charges,80% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$6.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.21 ,$8.22 ,
Bilirubin Direct,15269,CDM,301,RC,82248,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.02 ,$35.15 ,
Bilirubin Indirect,150484,CDM,301,RC,82247,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.02 ,$35.15 ,
Bilirubin Neonatal,150485,CDM,301,RC,82247,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.02 ,$35.15 ,
Bilirubin Total,10,CDM,300,RC,82247,HCPCS,outpatient,,,$7.00 ,$2.45 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.60 ,80,,,percent of total billed charges,80% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$6.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.21 ,$8.22 ,
Bilirubin Total and Direct,15048,CDM,301,RC,82247,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.12 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.02 ,$35.15 ,
Bill Only AP 88304 Surg Level III,88304,CDM,312,RC,88304,HCPCS,outpatient,,,$94.00 ,$32.90 ,,$31.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$47.00 ,75,,,percent of total billed charges,75% of total billed charges,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$75.20 ,80,,,percent of total billed charges,80% of total billed charges,$29.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.11 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.25 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$29.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$84.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$89.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.60 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$79.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.25 ,$89.30 ,
Bill Only PT/INR POC,,CDM,300,RC,85610,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.29 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.29 ,$133.00 ,
Blood Gas Arterial,120011,CDM,300,RC,82803,HCPCS,outpatient,,,$188.76 ,$66.07 ,,$25.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$25.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$151.01 ,80,,,percent of total billed charges,80% of total billed charges,$59.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.56 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.34 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.07 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$169.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$179.32 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$24.34 ,$179.32 ,
Blood Gas Venous,633677,CDM,300,RC,82803,HCPCS,outpatient,,,$188.76 ,$66.07 ,,$25.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$25.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$94.38 ,75,,,percent of total billed charges,75% of total billed charges,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$151.01 ,80,,,percent of total billed charges,80% of total billed charges,$59.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.56 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.34 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.07 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$169.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$179.32 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$160.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$24.34 ,$179.32 ,
Blood Urea Nitrogen,15054,CDM,301,RC,84520,HCPCS,outpatient,,,$79.00 ,$27.65 ,,$5.21 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.21 ,100,,,fee schedule,100% Amerigroup fee schedule,$39.50 ,75,,,percent of total billed charges,75% of total billed charges,$39.50 ,75,,,percent of total billed charges,75% of total billed charges,$39.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.20 ,80,,,percent of total billed charges,80% of total billed charges,$24.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.21 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.06 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.96 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.95 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$71.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.45 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.06 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$59.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$67.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.06 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.95 ,$75.05 ,
Breath Alcohol,16006,CDM,300,RC,82075,HCPCS,outpatient,,,$29.00 ,$10.15 ,,$10.61 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.61 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$23.20 ,80,,,percent of total billed charges,80% of total billed charges,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.30 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.00 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.66 ,$30.60 ,
"C difficile Toxins A+B, EIA LC",8447689,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
C-Reactive Protein,153053,CDM,300,RC,86140,HCPCS,outpatient,,,$202.00 ,$70.70 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$161.60 ,80,,,percent of total billed charges,80% of total billed charges,$63.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$191.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$191.90 ,
C-Reactive Protein High Sensitivity,15305d,CDM,300,RC,86140,HCPCS,outpatient,,,$202.00 ,$70.70 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$161.60 ,80,,,percent of total billed charges,80% of total billed charges,$63.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$191.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$191.90 ,
"C-Reactive Protein, Quant LC",15305,CDM,300,RC,86140,HCPCS,outpatient,,,$202.00 ,$70.70 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$101.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$161.60 ,80,,,percent of total billed charges,80% of total billed charges,$63.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$141.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$191.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$171.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$191.90 ,
C-Reactive Protein,30239,CDM,300,RC,86141,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.95 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.61 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.95 ,$40.85 ,
C-Reactive Protein High Sensitivity TC,86141,CDM,300,RC,86141,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.95 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.61 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.95 ,$40.85 ,
"CA 125, Serum (Serial) LC",39001302,CDM,300,RC,86304,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.23 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$27.47 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.68 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$20.81 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$34.01 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.68 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.94 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.68 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$20.81 ,$34.01 ,
CBC w/ Diff,15055,CDM,305,RC,85025,HCPCS,outpatient,,,$146.16 ,$51.16 ,,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$73.08 ,75,,,percent of total billed charges,75% of total billed charges,$73.08 ,75,,,percent of total billed charges,75% of total billed charges,$73.08 ,75,,,percent of total billed charges,75% of total billed charges,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$116.93 ,80,,,percent of total billed charges,80% of total billed charges,$46.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$116.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$138.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.97 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$109.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$124.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.77 ,$138.85 ,
CBC w/ Differential LC,150552,CDM,305,RC,85025,HCPCS,outpatient,,,$100.21 ,$35.07 ,,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$80.17 ,80,,,percent of total billed charges,80% of total billed charges,$31.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$80.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$90.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$95.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.97 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.77 ,$95.20 ,
CBC w/ Man Diff,150553,CDM,305,RC,85025,HCPCS,outpatient,,,$100.21 ,$35.07 ,,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$50.11 ,75,,,percent of total billed charges,75% of total billed charges,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.93 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$80.17 ,80,,,percent of total billed charges,80% of total billed charges,$31.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$80.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.77 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$90.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$95.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.97 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$85.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.97 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.77 ,$95.20 ,
CBC w/o Diff,16085,CDM,300,RC,85027,HCPCS,outpatient,,,$215.32 ,$75.36 ,,$8.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$172.26 ,80,,,percent of total billed charges,80% of total billed charges,$68.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.55 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$172.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$150.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$165.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.30 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.14 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$193.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.58 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$204.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.30 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$161.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$161.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$161.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$183.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.30 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.47 ,$204.55 ,
CEA LC,8388987,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
CK,15408,CDM,301,RC,82553,HCPCS,outpatient,,,$76.51 ,$26.78 ,,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$61.21 ,80,,,percent of total billed charges,80% of total billed charges,$24.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.25 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.55 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.55 ,$72.68 ,
"CK, CKMB and %MB Pnl",154081,CDM,301,RC,82553,HCPCS,outpatient,,,$76.51 ,$26.78 ,,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$61.21 ,80,,,percent of total billed charges,80% of total billed charges,$24.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.25 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.55 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.55 ,$72.68 ,
CK-MB,154086,CDM,301,RC,82553,HCPCS,outpatient,,,$76.51 ,$26.78 ,,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$38.26 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$61.21 ,80,,,percent of total billed charges,80% of total billed charges,$24.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.25 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.55 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$65.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.55 ,$72.68 ,
CK-MB,82553,CDM,300,RC,82553,HCPCS,outpatient,,,$107.00 ,$37.45 ,,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.25 ,100,,,fee schedule,100% Amerigroup fee schedule,$53.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.50 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$85.60 ,80,,,percent of total billed charges,80% of total billed charges,$33.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.25 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$85.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.55 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$96.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$101.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$90.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.55 ,$101.65 ,
CMP,16038,CDM,301,RC,80053,HCPCS,outpatient,,,$275.52 ,$96.43 ,,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$137.76 ,75,,,percent of total billed charges,75% of total billed charges,$137.76 ,75,,,percent of total billed charges,75% of total billed charges,$137.76 ,75,,,percent of total billed charges,75% of total billed charges,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$220.42 ,80,,,percent of total billed charges,80% of total billed charges,$87.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$220.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$212.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.29 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.56 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$247.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.28 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$261.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$206.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$206.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$206.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$234.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.56 ,$261.74 ,
CMP (BMP prior),16038,CDM,301,RC,80053,HCPCS,outpatient,,,$88.55 ,$30.99 ,,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$44.28 ,75,,,percent of total billed charges,75% of total billed charges,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$70.84 ,80,,,percent of total billed charges,80% of total billed charges,$28.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.29 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.56 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.28 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$84.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.56 ,$84.12 ,
CMP 14 LC,160388,CDM,301,RC,80053,HCPCS,outpatient,,,$197.00 ,$68.95 ,,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.95 ,100,,,fee schedule,100% Amerigroup fee schedule,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$98.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.77 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$157.60 ,80,,,percent of total billed charges,80% of total billed charges,$62.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$157.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.67 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.29 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.56 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$177.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.28 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$187.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$167.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.56 ,$187.15 ,
COLLECTION: Arterial Draw,12007,CDM,300,RC,36600,HCPCS,outpatient,,,$111.95 ,$39.18 ,,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.83 ,$106.35 ,
COLLECTION: Capillary,1779397,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COLLECTION: Capillary,1779397,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COLLECTION: Venous Draw,15410,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COLLECTION: Venous Draw,,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"CPK Isoenzymes - BB, MB, MM SF",15075,CDM,301,RC,82550,HCPCS,outpatient,,,$45.76 ,$16.02 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$22.88 ,75,,,percent of total billed charges,75% of total billed charges,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.64 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.61 ,80,,,percent of total billed charges,80% of total billed charges,$14.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.58 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.51 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$43.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.35 ,$43.47 ,
CRP LC,30239,CDM,300,RC,86141,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.21 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.95 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.61 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.95 ,$40.85 ,
CSF Cell Count w/Diff,16269,CDM,306,RC,87071,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$103.55 ,
CSF Differential,LAB0005,CDM,300,RC,85032,HCPCS,outpatient,,,$4.31 ,$1.51 ,,$4.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.45 ,80,,,percent of total billed charges,80% of total billed charges,$1.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$4.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$1.36 ,$7.03 ,
"CT, NG, Trich Vag by NAA LC",9149746,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Calcitriol(1,25 di-OH Vit D) LC",8447685,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Calcium,15058,CDM,301,RC,82310,HCPCS,outpatient,,,$51.00 ,$17.85 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$25.50 ,75,,,percent of total billed charges,75% of total billed charges,$25.50 ,75,,,percent of total billed charges,75% of total billed charges,$25.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.80 ,80,,,percent of total billed charges,80% of total billed charges,$16.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.21 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.16 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$48.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$38.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$43.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.16 ,$48.45 ,
"Calcium, Ionized, Serum LC",8447633,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Campylobacter Antigen,30177,CDM,300,RC,87046,HCPCS,outpatient,,,$70.25 ,$24.59 ,,$3.12 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.12 ,100,,,fee schedule,100% Amerigroup fee schedule,$35.13 ,75,,,percent of total billed charges,75% of total billed charges,$35.13 ,75,,,percent of total billed charges,75% of total billed charges,$35.13 ,75,,,percent of total billed charges,75% of total billed charges,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$56.20 ,80,,,percent of total billed charges,80% of total billed charges,$22.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.12 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.97 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.44 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$66.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$52.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.06 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$59.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.97 ,$66.74 ,
Carbamazepine Level,15284,CDM,300,RC,80156,HCPCS,outpatient,,,$62.00 ,$21.70 ,,$19.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$49.60 ,80,,,percent of total billed charges,80% of total billed charges,$19.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.72 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.31 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.57 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$58.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.68 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.57 ,$58.90 ,
Carbon Dioxide Level,89,CDM,301,RC,82374,HCPCS,outpatient,,,$7.00 ,$2.45 ,,$6.46 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.46 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.60 ,80,,,percent of total billed charges,80% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.46 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.15 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.88 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.00 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$6.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.27 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.33 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.21 ,$8.00 ,
Carcinoembryonic Antigen,15065,CDM,300,RC,82378,HCPCS,outpatient,,,$64.00 ,$22.40 ,,$25.05 ,100,,,fee schedule,100% Amerigroup fee schedule,$25.05 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.00 ,75,,,percent of total billed charges,75% of total billed charges,$32.00 ,75,,,percent of total billed charges,75% of total billed charges,$32.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.20 ,80,,,percent of total billed charges,80% of total billed charges,$20.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.05 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.34 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.15 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$18.96 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$57.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.02 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.34 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.58 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$54.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.34 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$18.96 ,$60.80 ,
Cardiac Profile,16189,CDM,300,RC,84484,HCPCS,outpatient,,,$162.31 ,$56.81 ,,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$81.16 ,75,,,percent of total billed charges,75% of total billed charges,$81.16 ,75,,,percent of total billed charges,75% of total billed charges,$81.16 ,75,,,percent of total billed charges,75% of total billed charges,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$129.85 ,80,,,percent of total billed charges,80% of total billed charges,$51.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$129.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.38 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$146.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$154.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.63 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$137.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.38 ,$154.19 ,
Cardiac Profile,LAB0004,CDM,300,RC,,HCPCS,outpatient,,,$227.00 ,$79.45 ,,$121.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.50 ,75,,,percent of total billed charges,75% of total billed charges,$113.50 ,75,,,percent of total billed charges,75% of total billed charges,$113.50 ,75,,,percent of total billed charges,75% of total billed charges,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$181.60 ,80,,,percent of total billed charges,80% of total billed charges,$71.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$158.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$174.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$204.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$170.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$192.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.27 ,$215.65 ,
Cell Count with Differential CSF,15066,CDM,300,RC,89051,HCPCS,outpatient,,,$121.00 ,$42.35 ,,$2.32 ,100,,,fee schedule,100% Amerigroup fee schedule,$2.32 ,100,,,fee schedule,100% Amerigroup fee schedule,$60.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$96.80 ,80,,,percent of total billed charges,80% of total billed charges,$38.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$2.32 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$96.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.25 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.66 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.60 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$108.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$114.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.25 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.28 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$102.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.25 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.21 ,$114.95 ,
"Cell Count, Serous Fluid LC",8810637,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Ceruloplasmin LC,8388986,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Chlamydia/GC Amplification LC,8447809,CDM,300,RC,86631,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.06 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.61 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.17 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$14.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.82 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$19.33 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.17 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$15.17 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.82 ,$19.33 ,
"Chlamydia/GC NAA, Confirmation LC",16307,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Chloride Level,15068,CDM,300,RC,82435,HCPCS,outpatient,,,$38.00 ,$13.30 ,,$6.07 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.07 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.40 ,80,,,percent of total billed charges,80% of total billed charges,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.07 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.60 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.60 ,$36.10 ,
Chloride Level 24 Hour Urine,16098,CDM,300,RC,82436,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.75 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.75 ,$39.90 ,
Chloride Level Urine,15069,CDM,300,RC,82436,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.87 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.75 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.22 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.45 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.45 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.75 ,$39.90 ,
Cholesterol Total,15070,CDM,301,RC,82465,HCPCS,outpatient,,,$60.00 ,$21.00 ,,$5.74 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.74 ,100,,,fee schedule,100% Amerigroup fee schedule,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.44 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$48.00 ,80,,,percent of total billed charges,80% of total billed charges,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.74 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.35 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$54.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$57.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.58 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.63 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,$57.00 ,
Clostridium Difficile,15419,CDM,300,RC,87493,HCPCS,outpatient,,,$302.80 ,$105.98 ,,$162.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$151.40 ,75,,,percent of total billed charges,75% of total billed charges,$151.40 ,75,,,percent of total billed charges,75% of total billed charges,$151.40 ,75,,,percent of total billed charges,75% of total billed charges,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$242.24 ,80,,,percent of total billed charges,80% of total billed charges,$95.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$105.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$242.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$211.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$233.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.64 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$272.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$287.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$227.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$257.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.27 ,$287.66 ,
Collection Processing Fee,15900,CDM,300,RC,,HCPCS,outpatient,,,$20.00 ,$7.00 ,,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.90 ,$19.00 ,
Collection for police,10587604,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Complement C3, Serum LC",8447643,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Complement C4, Serum LC",8447605,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Complement, Total (CH50) LC",8447606,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Copper, Serum LC",162521,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Coronavirus SARS Ag (Sofia),30242D2,CDM,300,RC,87426,HCPCS,outpatient,,,$82.23 ,$28.78 ,,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$65.78 ,80,,,percent of total billed charges,80% of total billed charges,$26.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.33 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$74.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$78.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.00 ,$78.12 ,
Cortisol LC,8447618,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Creatinine,15077,CDM,301,RC,82565,HCPCS,outpatient,,,$124.80 ,$43.68 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$62.40 ,75,,,percent of total billed charges,75% of total billed charges,$62.40 ,75,,,percent of total billed charges,75% of total billed charges,$62.40 ,75,,,percent of total billed charges,75% of total billed charges,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$99.84 ,80,,,percent of total billed charges,80% of total billed charges,$39.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.12 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$118.56 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$106.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.12 ,$118.56 ,
Creatinine Clearance,15078,CDM,300,RC,82575,HCPCS,outpatient,,,$55.00 ,$19.25 ,,$12.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$27.50 ,75,,,percent of total billed charges,75% of total billed charges,$27.50 ,75,,,percent of total billed charges,75% of total billed charges,$27.50 ,75,,,percent of total billed charges,75% of total billed charges,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$44.00 ,80,,,percent of total billed charges,80% of total billed charges,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.47 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.88 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.46 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.44 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.24 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.46 ,$52.25 ,
Creatinine Level 24 Hour Urine,16248,CDM,300,RC,82570,HCPCS,outpatient,,,$63.23 ,$22.13 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$50.58 ,80,,,percent of total billed charges,80% of total billed charges,$19.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$60.07 ,
Creatinine Urine,15819,CDM,300,RC,82570,HCPCS,outpatient,,,$63.23 ,$22.13 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$50.58 ,80,,,percent of total billed charges,80% of total billed charges,$19.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$53.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$60.07 ,
"Cryoglobulin, Ql, Serum, Rflx LC",8473292,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
D-Dimer,16062,CDM,300,RC,85379,HCPCS,outpatient,,,$344.23 ,$120.48 ,,$13.44 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.44 ,100,,,fee schedule,100% Amerigroup fee schedule,$172.12 ,75,,,percent of total billed charges,75% of total billed charges,$172.12 ,75,,,percent of total billed charges,75% of total billed charges,$172.12 ,75,,,percent of total billed charges,75% of total billed charges,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$275.38 ,80,,,percent of total billed charges,80% of total billed charges,$108.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.44 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$275.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$240.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$265.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.06 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.28 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$309.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$327.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.06 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$320.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$258.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$258.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$258.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.18 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$292.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.06 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.18 ,$327.02 ,
DECALCIFICATION,16162,CDM,312,RC,88311,HCPCS,outpatient,,,$38.00 ,$13.30 ,,$16.22 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.22 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.40 ,80,,,percent of total billed charges,80% of total billed charges,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.81 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.89 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.92 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.81 ,$36.10 ,
DNA TESTING,12639,CDM,300,RC,,HCPCS,outpatient,,,$20.00 ,$7.00 ,,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.90 ,$19.00 ,
"DRUG SCREEN, SERUM CPL CPL",16068,CDM,300,RC,80307,HCPCS,outpatient,,,$80.00 ,$80.00 ,,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.00 ,75,,,percent of total billed charges,75% of total billed charges,$40.00 ,75,,,percent of total billed charges,75% of total billed charges,$40.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$64.00 ,80,,,percent of total billed charges,80% of total billed charges,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$72.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$76.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$25.30 ,$79.51 ,
Digoxin Lvl,15085,CDM,300,RC,80162,HCPCS,outpatient,,,$62.00 ,$21.70 ,,$17.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$49.60 ,80,,,percent of total billed charges,80% of total billed charges,$19.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.54 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.41 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.70 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.28 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$58.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.28 ,$58.90 ,
"Drug Profile, Ur, 9 Drugs LC",15830,CDM,300,RC,80100,HCPCS,outpatient,,,$76.00 ,$26.60 ,,$18.39 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.39 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$38.00 ,75,,,percent of total billed charges,75% of total billed charges,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.80 ,80,,,percent of total billed charges,80% of total billed charges,$24.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$68.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.82 ,$72.20 ,
Drug Screen Note: LC,16052,CDM,300,RC,80307,HCPCS,outpatient,,,$29.00 ,$29.00 ,,$15.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$23.20 ,80,,,percent of total billed charges,80% of total billed charges,$9.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$27.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.17 ,$79.51 ,
Drug Screen Urine,3550255,CDM,300,RC,80306,HCPCS,outpatient,,,$88.66 ,$88.66 ,,$47.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.33 ,75,,,percent of total billed charges,75% of total billed charges,$44.33 ,75,,,percent of total billed charges,75% of total billed charges,$44.33 ,75,,,percent of total billed charges,75% of total billed charges,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.48 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$70.93 ,80,,,percent of total billed charges,80% of total billed charges,$28.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.05 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.29 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$17.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$84.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.60 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.29 ,$84.23 ,
Drug Screen- Collection Only DOT,16056,CDM,300,RC,80307,HCPCS,outpatient,,,$50.00 ,$50.00 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.00 ,75,,,percent of total billed charges,75% of total billed charges,$25.00 ,75,,,percent of total billed charges,75% of total billed charges,$25.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.81 ,$79.51 ,
EBV Antibody Profile LC,8447817,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Electrolyte Panel,15089,CDM,301,RC,80051,HCPCS,outpatient,,,$62.00 ,$21.70 ,,$9.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.26 ,100,,,fee schedule,100% Amerigroup fee schedule,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$31.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.15 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$49.60 ,80,,,percent of total billed charges,80% of total billed charges,$19.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.26 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.08 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.82 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.01 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.47 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$58.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.00 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.01 ,$58.90 ,
Estradiol LC,,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Estrogens, Total LC",8447630,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
FSH and LH LC,8447790,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"FSH, Serum LC",15101,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Fecal Occult Blood (Guaiac FOB),16092,CDM,300,RC,82270,HCPCS,outpatient,,,$40.00 ,$14.00 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.47 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.38 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$38.00 ,
Fecal WBC,15198,CDM,306,RC,87205,HCPCS,outpatient,,,$37.18 ,$13.01 ,,$3.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.74 ,80,,,percent of total billed charges,80% of total billed charges,$11.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.10 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.01 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.84 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.32 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.01 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.01 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.95 ,$35.32 ,
Fern Test,16156,CDM,306,RC,87210,HCPCS,outpatient,,,$12.00 ,$4.20 ,,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.60 ,80,,,percent of total billed charges,80% of total billed charges,$3.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.63 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.36 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.82 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$11.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.47 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.79 ,$11.40 ,
Ferritin,150972,CDM,300,RC,82728,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$17.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.13 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.63 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.47 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.63 ,$91.20 ,
"Ferritin, Serum LC",15097,CDM,300,RC,82728,HCPCS,outpatient,,,$68.64 ,$24.02 ,,$17.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.99 ,100,,,fee schedule,100% Amerigroup fee schedule,$34.32 ,75,,,percent of total billed charges,75% of total billed charges,$34.32 ,75,,,percent of total billed charges,75% of total billed charges,$34.32 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$54.91 ,80,,,percent of total billed charges,80% of total billed charges,$21.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$54.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.13 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.63 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$65.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.47 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$51.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$58.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.63 ,$65.21 ,
Fibrinogen Activity LC,15098,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Flu A+B (Sofia),16058,CDM,300,RC,87400,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.21 ,$36.68 ,
Folate Level,161411,CDM,300,RC,82747,HCPCS,outpatient,,,$30.75 ,$10.76 ,,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.60 ,80,,,percent of total billed charges,80% of total billed charges,$9.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.87 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$17.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.72 ,$29.21 ,
Folate Level,15099E,CDM,301,RC,82746,HCPCS,outpatient,,,$56.49 ,$19.77 ,,$19.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$28.25 ,75,,,percent of total billed charges,75% of total billed charges,$28.25 ,75,,,percent of total billed charges,75% of total billed charges,$28.25 ,75,,,percent of total billed charges,75% of total billed charges,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$45.19 ,80,,,percent of total billed charges,80% of total billed charges,$17.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.49 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.70 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$53.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$48.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.70 ,$53.67 ,
Folate Level,16141,CDM,300,RC,82746,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$19.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.99 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.49 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.70 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.60 ,$40.85 ,
Forensic 10 Drug Screen Profile Ref Lab,80307,CDM,300,RC,80307,HCPCS,outpatient,,,$45.00 ,$45.00 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.23 ,$79.51 ,
Forensic 5 Drug Screen,16011,CDM,300,RC,80307,HCPCS,outpatient,,,$40.00 ,$40.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.65 ,$79.51 ,
Forensic 7 Drug Screen for City of Hazlehurst,16071,CDM,300,RC,80307,HCPCS,outpatient,,,$40.00 ,$40.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$20.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.65 ,$79.51 ,
Forensic 7 Drug Screen,16027,CDM,300,RC,80307,HCPCS,outpatient,,,$62.14 ,$62.14 ,,$33.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.07 ,75,,,percent of total billed charges,75% of total billed charges,$31.07 ,75,,,percent of total billed charges,75% of total billed charges,$31.07 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$49.71 ,80,,,percent of total billed charges,80% of total billed charges,$19.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$49.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$59.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$52.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.65 ,$79.51 ,
Forensic 7 Ref. Lab,80307,CDM,300,RC,,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
"Free K+L Lt Chains,Qn,S LC",8447767,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Free K+L Lt Chains,Qn,Ur LC",10453370,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Free T4 Level,15200,CDM,300,RC,84439,HCPCS,outpatient,,,$104.39 ,$36.54 ,,$11.91 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.91 ,100,,,fee schedule,100% Amerigroup fee schedule,$52.20 ,75,,,percent of total billed charges,75% of total billed charges,$52.20 ,75,,,percent of total billed charges,75% of total billed charges,$52.20 ,75,,,percent of total billed charges,75% of total billed charges,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.20 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$83.51 ,80,,,percent of total billed charges,80% of total billed charges,$33.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.91 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$83.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.57 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.34 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$93.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.74 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$99.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.57 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.68 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$88.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.57 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.02 ,$99.17 ,
Free T4 Level,84439,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Fungus (Mycology) Culture LC,15801,CDM,300,RC,87102,HCPCS,outpatient,,,$214.00 ,$74.90 ,,$11.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.58 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$171.20 ,80,,,percent of total billed charges,80% of total billed charges,$67.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.10 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.78 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.49 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.57 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.41 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$192.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.74 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$203.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.78 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.89 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.78 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.41 ,$203.30 ,
GGT LC,15106,CDM,300,RC,82977,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.20 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.35 ,$8.26 ,
Gamma Glutamyl Transferase,15106,CDM,300,RC,82977,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.34 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.20 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.35 ,$8.26 ,
Gastric Occult Blood,15849,CDM,300,RC,82271,HCPCS,outpatient,,,$49.00 ,$17.15 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.43 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.20 ,80,,,percent of total billed charges,80% of total billed charges,$15.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.32 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$41.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$46.55 ,
Gentamicin Lvl Peak,16227,CDM,300,RC,80170,HCPCS,outpatient,,,$74.00 ,$25.90 ,,$21.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$59.20 ,80,,,percent of total billed charges,80% of total billed charges,$23.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.02 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.38 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.79 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$70.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.02 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.23 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.02 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.38 ,$70.30 ,
Gentamicin Lvl Trough,16228,CDM,300,RC,80170,HCPCS,outpatient,,,$74.00 ,$25.90 ,,$21.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$59.20 ,80,,,percent of total billed charges,80% of total billed charges,$23.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.02 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.54 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.38 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.79 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$70.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.02 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.23 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.02 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.38 ,$70.30 ,
Gestational Diabetes Screen,153277,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
Giardia/Crypto Ag,16135,CDM,300,RC,87329,HCPCS,outpatient,,,$120.83 ,$42.29 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$60.42 ,75,,,percent of total billed charges,75% of total billed charges,$60.42 ,75,,,percent of total billed charges,75% of total billed charges,$60.42 ,75,,,percent of total billed charges,75% of total billed charges,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$96.66 ,80,,,percent of total billed charges,80% of total billed charges,$38.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$96.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.98 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$108.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$114.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$102.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.98 ,$114.79 ,
Glucose 2 Hour Post Prandial,153278,CDM,300,RC,82947,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$39.90 ,
Glucose CSF,15194,CDM,300,RC,82945,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$18.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$35.15 ,
Glucose Level,15107,CDM,301,RC,82947,HCPCS,outpatient,,,$49.34 ,$17.27 ,,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$24.67 ,75,,,percent of total billed charges,75% of total billed charges,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.47 ,80,,,percent of total billed charges,80% of total billed charges,$15.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.93 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.03 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.08 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$41.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.93 ,$46.87 ,
Glucose POCT,1635509,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Glucose, Body Fluid LC",8447679,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
H&H,15116,CDM,305,RC,85014,HCPCS,outpatient,,,$30.91 ,$10.82 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.73 ,80,,,percent of total billed charges,80% of total billed charges,$9.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$29.36 ,
HBsAg Screen LC,15802,CDM,300,RC,87340,HCPCS,outpatient,,,$23.00 ,$8.05 ,,$13.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.50 ,75,,,percent of total billed charges,75% of total billed charges,$11.50 ,75,,,percent of total billed charges,75% of total billed charges,$11.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.54 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.40 ,80,,,percent of total billed charges,80% of total billed charges,$7.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.25 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.43 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.33 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.89 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.25 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$19.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.25 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.27 ,$21.85 ,
HCV Antibody LC,8447722,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"HCV RT-PCR, Quant (Non-Graph) LC",8447908,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
HDL Cholesterol,15333,CDM,300,RC,83718,HCPCS,outpatient,,,$66.00 ,$23.10 ,,$10.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.80 ,80,,,percent of total billed charges,80% of total billed charges,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.51 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.30 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.19 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.39 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.51 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.61 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.51 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.19 ,$62.70 ,
HIV Ag/Ab w/ Reflex to Conf LC,16262,CDM,300,RC,86703,HCPCS,outpatient,,,$43.00 ,$15.05 ,,$12.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$21.50 ,75,,,percent of total billed charges,75% of total billed charges,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.98 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$34.40 ,80,,,percent of total billed charges,80% of total billed charges,$13.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.71 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.26 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.85 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.96 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.71 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.45 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.26 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.26 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.08 ,$40.85 ,
HSV 1/2 PCR LC,LAB0040,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Haptoglobin LC,8447601,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Helicobacter Pylori Stool Antigen,15807,CDM,300,RC,86677,HCPCS,outpatient,,,$168.00 ,$58.80 ,,$19.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.16 ,100,,,fee schedule,100% Amerigroup fee schedule,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$134.40 ,80,,,percent of total billed charges,80% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.16 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.62 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.02 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.25 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.85 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.73 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$159.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.62 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.62 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.85 ,$159.60 ,
Hematocrit LC,151166,CDM,305,RC,85014,HCPCS,outpatient,,,$30.91 ,$10.82 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$15.46 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.73 ,80,,,percent of total billed charges,80% of total billed charges,$9.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$29.36 ,
Hemoglobin A1c LC,15112,CDM,301,RC,83036,HCPCS,outpatient,,,$153.00 ,$53.55 ,,$12.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$122.40 ,80,,,percent of total billed charges,80% of total billed charges,$48.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.81 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$122.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.20 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.71 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$137.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$145.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.44 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.71 ,$145.35 ,
Hemoglobin LC,15117,CDM,305,RC,85018,HCPCS,outpatient,,,$15.73 ,$5.51 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.58 ,80,,,percent of total billed charges,80% of total billed charges,$4.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$14.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$14.94 ,
Hepatic Function Panel,160377,CDM,301,RC,80076,HCPCS,outpatient,,,$207.98 ,$72.79 ,,$10.79 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.79 ,100,,,fee schedule,100% Amerigroup fee schedule,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$166.38 ,80,,,percent of total billed charges,80% of total billed charges,$65.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.79 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$166.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$160.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.17 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$197.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.49 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.17 ,$197.58 ,
Hepatic Function Panel (7) LC,16037,CDM,301,RC,80076,HCPCS,outpatient,,,$207.98 ,$72.79 ,,$10.79 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.79 ,100,,,fee schedule,100% Amerigroup fee schedule,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$166.38 ,80,,,percent of total billed charges,80% of total billed charges,$65.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.79 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$166.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$160.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.25 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.17 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$187.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$197.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.49 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$176.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.17 ,$197.58 ,
Hepatitis B Surf Ab Quant LC,8447647,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Hepatitis Panel (4) LC,8447904,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Hgb,15117,CDM,305,RC,85018,HCPCS,outpatient,,,$15.73 ,$5.51 ,,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.13 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.87 ,75,,,percent of total billed charges,75% of total billed charges,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.42 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.58 ,80,,,percent of total billed charges,80% of total billed charges,$4.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.13 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.39 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.37 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$14.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.37 ,$14.94 ,
Hgb A1c,151122,CDM,301,RC,83036,HCPCS,outpatient,,,$153.00 ,$53.55 ,,$12.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.81 ,100,,,fee schedule,100% Amerigroup fee schedule,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$76.50 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$122.40 ,80,,,percent of total billed charges,80% of total billed charges,$48.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.81 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$122.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.20 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.71 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$137.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.86 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$145.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.44 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$130.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.71 ,$145.35 ,
Homocyst(e)ine LC,8447759,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Immunofixation, Serum LC",8388997,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Immunoglobulins A/E/G/M, Serum LC",8447779,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Influenza A,16058E,CDM,300,RC,87400,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.21 ,$36.68 ,
Influenza B,16059E,CDM,300,RC,87400,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$19.31 ,75,,,percent of total billed charges,75% of total billed charges,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.41 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.21 ,$36.68 ,
"Intrinsic Factor Abs, Serum LC",8447669,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Iron Level,15391,CDM,300,RC,83540,HCPCS,outpatient,,,$71.66 ,$25.08 ,,$8.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.56 ,100,,,fee schedule,100% Amerigroup fee schedule,$35.83 ,75,,,percent of total billed charges,75% of total billed charges,$35.83 ,75,,,percent of total billed charges,75% of total billed charges,$35.83 ,75,,,percent of total billed charges,75% of total billed charges,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$57.33 ,80,,,percent of total billed charges,80% of total billed charges,$22.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.56 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$57.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.15 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$64.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$68.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.31 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.39 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.31 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.47 ,$68.08 ,
Iron Level and TIBC,153925,CDM,300,RC,83550,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.54 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.29 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,$71.25 ,
Iron Level and TIBC,16202,CDM,300,RC,83550,HCPCS,outpatient,,,$53.63 ,$18.77 ,,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.90 ,80,,,percent of total billed charges,80% of total billed charges,$16.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.54 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.29 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$50.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,$50.95 ,
Iron and TIBC LC,153922,CDM,300,RC,83550,HCPCS,outpatient,,,$53.63 ,$18.77 ,,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.90 ,80,,,percent of total billed charges,80% of total billed charges,$16.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.54 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.29 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$50.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,$50.95 ,
Ketones Serum,15019,CDM,300,RC,82009,HCPCS,outpatient,,,$21.45 ,$7.51 ,,$4.34 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.34 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.16 ,80,,,percent of total billed charges,80% of total billed charges,$6.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.34 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.16 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.13 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.52 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.37 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$20.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.16 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$18.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.13 ,$20.38 ,
LDL Direct,16041,CDM,300,RC,83721,HCPCS,outpatient,,,$48.00 ,$16.80 ,,$12.60 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.60 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$24.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.71 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.40 ,80,,,percent of total billed charges,80% of total billed charges,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.60 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.61 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.50 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.50 ,$45.60 ,
Lab Collection Supplies Fee,16138,CDM,270,RC,,HCPCS,outpatient,,,$15.00 ,$5.25 ,,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.93 ,$14.25 ,
Lab One Collection,15901,CDM,300,RC,,HCPCS,outpatient,,,$14.00 ,$4.90 ,,$7.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.20 ,80,,,percent of total billed charges,80% of total billed charges,$4.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.73 ,$13.30 ,
Labcorp Collection LC,16252,CDM,300,RC,,HCPCS,outpatient,,,$8.00 ,$2.80 ,,$4.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$4.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$4.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.00 ,75,,,percent of total billed charges,75% of total billed charges,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.40 ,80,,,percent of total billed charges,80% of total billed charges,$2.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$2.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$6.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$2.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$7.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$1.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$7.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$6.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$1.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$6.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.56 ,$7.60 ,
Lactate Dehydrogenase,15130,CDM,301,RC,83615,HCPCS,outpatient,,,$22.88 ,$8.01 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.30 ,80,,,percent of total billed charges,80% of total billed charges,$7.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.04 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.04 ,$21.74 ,
Lactic Acid,15344,CDM,300,RC,83605,HCPCS,outpatient,,,$36.47 ,$12.76 ,,$14.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$11.80 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.18 ,80,,,percent of total billed charges,80% of total billed charges,$11.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.10 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.43 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.57 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.83 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.53 ,$34.65 ,
"Lamotrigine (Lamictal), Serum LC",1234,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Lead, Blood (Pediatric) LC",15132,CDM,300,RC,83655,HCPCS,outpatient,,,$78.00 ,$27.30 ,,$15.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.35 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$62.40 ,80,,,percent of total billed charges,80% of total billed charges,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.50 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.11 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.00 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$74.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.20 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.30 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.00 ,$74.10 ,
"Levetiracetam (Keppra), S LC",,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Lipase LC,151362,CDM,300,RC,83690,HCPCS,outpatient,,,$265.98 ,$93.09 ,,$9.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$212.78 ,80,,,percent of total billed charges,80% of total billed charges,$84.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$212.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$186.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$204.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.66 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$239.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$252.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.92 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.89 ,$252.68 ,
Lipase Level,15136,CDM,300,RC,83690,HCPCS,outpatient,,,$265.98 ,$93.09 ,,$9.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$132.99 ,75,,,percent of total billed charges,75% of total billed charges,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.03 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$212.78 ,80,,,percent of total billed charges,80% of total billed charges,$84.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$212.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$186.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$204.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.96 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.66 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$239.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$252.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.83 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.92 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$226.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.89 ,$252.68 ,
Lipid Panel LC,151377,CDM,301,RC,80061,HCPCS,outpatient,,,$130.13 ,$45.55 ,,$17.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$65.07 ,75,,,percent of total billed charges,75% of total billed charges,$65.07 ,75,,,percent of total billed charges,75% of total billed charges,$65.07 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$104.10 ,80,,,percent of total billed charges,80% of total billed charges,$41.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.69 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$104.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.19 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.85 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.39 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$117.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.91 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$123.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.19 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$110.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.19 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.39 ,$123.62 ,
Lipid Panel w/Direct LDL,15137,CDM,301,RC,80061,HCPCS,outpatient,,,$182.00 ,$63.70 ,,$17.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$91.00 ,75,,,percent of total billed charges,75% of total billed charges,$91.00 ,75,,,percent of total billed charges,75% of total billed charges,$91.00 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.66 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$145.60 ,80,,,percent of total billed charges,80% of total billed charges,$57.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.69 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$145.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.19 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.85 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.39 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$163.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.91 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$172.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.19 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$136.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$154.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.19 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.39 ,$172.90 ,
Lupus Anticoagulant Comp LC,8447871,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Luteinizing Hormone(LH), S LC",8447622,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Magnesium LC,151411,CDM,301,RC,83735,HCPCS,outpatient,,,$41.00 ,$14.35 ,,$8.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.80 ,80,,,percent of total billed charges,80% of total billed charges,$12.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.42 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.70 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.59 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.67 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.70 ,$38.95 ,
Magnesium Level,15141,CDM,301,RC,83735,HCPCS,outpatient,,,$41.00 ,$14.35 ,,$8.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$20.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.80 ,80,,,percent of total billed charges,80% of total billed charges,$12.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.42 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.70 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.59 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.67 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.70 ,$38.95 ,
Measles/Mumps/Rubella Immunity LC,8447783,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Microalbumin Level Urine,160618,CDM,300,RC,82043,HCPCS,outpatient,,,$54.34 ,$19.02 ,,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$43.47 ,80,,,percent of total billed charges,80% of total billed charges,$17.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.78 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$51.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.43 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.78 ,$51.62 ,
Microalbumin/Creatinine Ratio Urine,16061,CDM,300,RC,82043,HCPCS,outpatient,,,$54.34 ,$19.02 ,,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.64 ,100,,,fee schedule,100% Amerigroup fee schedule,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$27.17 ,75,,,percent of total billed charges,75% of total billed charges,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.90 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$43.47 ,80,,,percent of total billed charges,80% of total billed charges,$17.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.64 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.84 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.78 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$51.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.43 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$46.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.43 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.78 ,$51.62 ,
Miscellaneous Testing LC,8453255,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Mononucleosis Screen,15145,CDM,300,RC,86308,HCPCS,outpatient,,,$129.00 ,$45.15 ,,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$64.50 ,75,,,percent of total billed charges,75% of total billed charges,$64.50 ,75,,,percent of total billed charges,75% of total billed charges,$64.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$103.20 ,80,,,percent of total billed charges,80% of total billed charges,$40.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$103.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$99.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.18 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$116.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$122.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.64 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$109.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.64 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.18 ,$122.55 ,
NT-Pro BNP,161522,CDM,300,RC,83880,HCPCS,outpatient,,,$91.00 ,$31.85 ,,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$72.80 ,80,,,percent of total billed charges,80% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.69 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.26 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$86.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$28.77 ,$86.45 ,
NT-ProBNP II,16152,CDM,300,RC,83880,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.69 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.26 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$20.58 ,$61.82 ,
NT-proBNP LC,16152,CDM,300,RC,83880,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$40.05 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.65 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.69 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.26 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$20.58 ,$61.82 ,
Occult Blood Diagnostic 1st Spec,15146,CDM,306,RC,82272,HCPCS,outpatient,,,$16.00 ,$5.60 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.80 ,80,,,percent of total billed charges,80% of total billed charges,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$15.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$15.20 ,
Occult Blood Diagnostic 2nd Spec,15146,CDM,306,RC,82272,HCPCS,outpatient,,,$16.00 ,$5.60 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.80 ,80,,,percent of total billed charges,80% of total billed charges,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$15.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$15.20 ,
Occult Blood Diagnostic 3rd Spec,15146,CDM,306,RC,82272,HCPCS,outpatient,,,$16.00 ,$5.60 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.80 ,80,,,percent of total billed charges,80% of total billed charges,$5.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$15.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$13.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$15.20 ,
Occult Blood Digital Rectal,16116,CDM,300,RC,82272,HCPCS,outpatient,,,$28.60 ,$10.01 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$22.88 ,80,,,percent of total billed charges,80% of total billed charges,$9.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$22.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$27.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$27.17 ,
Occult Blood Screen,16092,CDM,300,RC,82272,HCPCS,outpatient,,,$28.60 ,$10.01 ,,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$14.30 ,75,,,percent of total billed charges,75% of total billed charges,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.31 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$22.88 ,80,,,percent of total billed charges,80% of total billed charges,$9.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.24 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$22.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.27 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$27.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,$27.17 ,
"Osmolality, Urine LC",15148,CDM,300,RC,83935,HCPCS,outpatient,,,$68.00 ,$23.80 ,,$9.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.96 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$54.40 ,80,,,percent of total billed charges,80% of total billed charges,$21.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$54.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.57 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.82 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$61.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.14 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$64.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.74 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$51.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.83 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$57.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.82 ,$64.60 ,
Ova + Parasite Exam LC,8389013,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
PSA Diagnostic,15417,CDM,301,RC,84153,HCPCS,outpatient,,,$36.47 ,$12.76 ,,$24.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.18 ,80,,,percent of total billed charges,80% of total billed charges,$11.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.29 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.13 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$18.39 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.59 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.82 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.53 ,$34.65 ,
PSA Screen,16039,CDM,300,RC,G0103,HCPCS,outpatient,,,$243.07 ,$85.07 ,,$130.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.54 ,75,,,percent of total billed charges,75% of total billed charges,$121.54 ,75,,,percent of total billed charges,75% of total billed charges,$121.54 ,75,,,percent of total billed charges,75% of total billed charges,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$19.70 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$194.46 ,80,,,percent of total billed charges,80% of total billed charges,$76.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$194.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$187.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.50 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.70 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$19.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$218.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$230.92 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$182.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.47 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$206.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$19.31 ,$230.92 ,
PT and PTT LC,151723,CDM,305,RC,85730,HCPCS,outpatient,,,$74.36 ,$26.03 ,,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$59.49 ,80,,,percent of total billed charges,80% of total billed charges,$23.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.92 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.54 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.01 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$70.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.69 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.01 ,$70.64 ,
PT/INR (Fingerstick),85610,CDM,300,RC,85610,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.29 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.29 ,$133.00 ,
"PTH, Intact LC",15150,CDM,300,RC,83970,HCPCS,outpatient,,,$65.78 ,$23.02 ,,$54.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$32.89 ,75,,,percent of total billed charges,75% of total billed charges,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.11 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.62 ,80,,,percent of total billed charges,80% of total billed charges,$20.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.50 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.94 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.69 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.90 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$41.28 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$67.47 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.94 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.94 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$20.80 ,$67.47 ,
PTT,15172,CDM,305,RC,85730,HCPCS,outpatient,,,$104.00 ,$36.40 ,,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$52.00 ,75,,,percent of total billed charges,75% of total billed charges,$52.00 ,75,,,percent of total billed charges,75% of total billed charges,$52.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$83.20 ,80,,,percent of total billed charges,80% of total billed charges,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.92 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.54 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.01 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$93.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$98.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.69 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.01 ,$98.80 ,
PTT,15170,CDM,300,RC,85610,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.29 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.29 ,$133.00 ,
Partial Thromboplastin Time,151721,CDM,305,RC,85730,HCPCS,outpatient,,,$74.36 ,$26.03 ,,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$37.18 ,75,,,percent of total billed charges,75% of total billed charges,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.13 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$59.49 ,80,,,percent of total billed charges,80% of total billed charges,$23.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.92 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$59.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.54 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.01 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$70.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.69 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.01 ,$70.64 ,
"Phenobarbital, Serum LC",8453279,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Phenytoin Lvl,15086,CDM,300,RC,80185,HCPCS,outpatient,,,$52.20 ,$18.27 ,,$17.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$26.10 ,75,,,percent of total billed charges,75% of total billed charges,$26.10 ,75,,,percent of total billed charges,75% of total billed charges,$26.10 ,75,,,percent of total billed charges,75% of total billed charges,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.52 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$41.76 ,80,,,percent of total billed charges,80% of total billed charges,$16.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.38 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.67 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.25 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$46.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.67 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$49.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.00 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$44.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.25 ,$49.59 ,
Phosphorus LC,151555,CDM,300,RC,84100,HCPCS,outpatient,,,$22.88 ,$8.01 ,,$6.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$11.44 ,75,,,percent of total billed charges,75% of total billed charges,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.30 ,80,,,percent of total billed charges,80% of total billed charges,$7.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.27 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.97 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.76 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.15 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$19.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.74 ,$21.74 ,
Phosphorus Level,15155,CDM,300,RC,84100,HCPCS,outpatient,,,$32.00 ,$11.20 ,,$6.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.83 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$25.60 ,80,,,percent of total billed charges,80% of total billed charges,$10.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.27 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.79 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.97 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.76 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$30.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.15 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$27.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.74 ,$30.40 ,
Pinworm Exam,16084,CDM,300,RC,87172,HCPCS,outpatient,,,$13.00 ,$4.55 ,,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.40 ,80,,,percent of total billed charges,80% of total billed charges,$4.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.63 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.36 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$11.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$12.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.47 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$11.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.11 ,$12.35 ,
Platelet Count,15159,CDM,305,RC,85049,HCPCS,outpatient,,,$36.00 ,$12.60 ,,$5.91 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.91 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.57 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$28.80 ,80,,,percent of total billed charges,80% of total billed charges,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.91 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.52 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.63 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.48 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.74 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.74 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.48 ,$34.20 ,
Potassium Level,15160,CDM,301,RC,84132,HCPCS,outpatient,,,$23.60 ,$8.26 ,,$6.07 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.07 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.88 ,80,,,percent of total billed charges,80% of total billed charges,$7.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.07 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.81 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.76 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$22.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.95 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.76 ,$22.42 ,
Potassium Level 24 Hour Urine,16257,CDM,300,RC,84133,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$5.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.73 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.73 ,$31.35 ,
Potassium Level Urine,15161,CDM,300,RC,84133,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$5.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.78 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.73 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.73 ,$31.35 ,
Prealbumin LC,16054,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Pregnancy Test Serum Qual,15359,CDM,300,RC,84703,HCPCS,outpatient,,,$146.89 ,$51.41 ,,$8.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$73.45 ,75,,,percent of total billed charges,75% of total billed charges,$73.45 ,75,,,percent of total billed charges,75% of total billed charges,$73.45 ,75,,,percent of total billed charges,75% of total billed charges,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$117.51 ,80,,,percent of total billed charges,80% of total billed charges,$46.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.47 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$117.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$7.60 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.07 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$7.52 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$132.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$139.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.23 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$110.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$124.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.52 ,$139.55 ,
Pregnancy Test Urine Qual,15162,CDM,300,RC,81025,HCPCS,outpatient,,,$144.72 ,$50.65 ,,$8.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$72.36 ,75,,,percent of total billed charges,75% of total billed charges,$72.36 ,75,,,percent of total billed charges,75% of total billed charges,$72.36 ,75,,,percent of total billed charges,75% of total billed charges,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.78 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$115.78 ,80,,,percent of total billed charges,80% of total billed charges,$45.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.36 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$115.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.61 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.35 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$137.48 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$123.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$7.96 ,$137.48 ,
Prolactin LC,8447628,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Prostate-Specific Ag LC,154177,CDM,301,RC,84153,HCPCS,outpatient,,,$36.47 ,$12.76 ,,$24.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$24.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.76 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.18 ,80,,,percent of total billed charges,80% of total billed charges,$11.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.29 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.13 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$18.39 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.59 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.82 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.59 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.53 ,$34.65 ,
Protein C Antigen LC,9533717,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Protein Cerebrospinal Fluid,16094,CDM,300,RC,84157,HCPCS,outpatient,,,$42.00 ,$14.70 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$21.00 ,75,,,percent of total billed charges,75% of total billed charges,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.60 ,80,,,percent of total billed charges,80% of total billed charges,$13.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.04 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.00 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.00 ,$39.90 ,
"Protein Electro, Random Urine LC",8447830,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Protein Electro.,S LC",8447823,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Protein Level 24 Hour Urine,16249,CDM,300,RC,84156,HCPCS,outpatient,,,$47.77 ,$16.72 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.22 ,80,,,percent of total billed charges,80% of total billed charges,$15.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.67 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.67 ,$45.38 ,
Protein S-Antigen LC,8473322,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Protein Total,15168,CDM,300,RC,84155,HCPCS,outpatient,,,$34.00 ,$11.90 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$27.20 ,80,,,percent of total billed charges,80% of total billed charges,$10.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.67 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$32.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$25.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.67 ,$32.30 ,
Protein Urine,160934,CDM,300,RC,84156,HCPCS,outpatient,,,$47.77 ,$16.72 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.22 ,80,,,percent of total billed charges,80% of total billed charges,$15.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.67 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.67 ,$45.38 ,
"Protein, Body Fluid LC",8447680,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Protein,Total,Urine LC",16093,CDM,300,RC,84156,HCPCS,outpatient,,,$47.77 ,$16.72 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.22 ,80,,,percent of total billed charges,80% of total billed charges,$15.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.67 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.67 ,$45.38 ,
Protein/Creatinine Ratio Urine,16093,CDM,300,RC,84156,HCPCS,outpatient,,,$47.77 ,$16.72 ,,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.84 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$23.89 ,75,,,percent of total billed charges,75% of total billed charges,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.74 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$38.22 ,80,,,percent of total billed charges,80% of total billed charges,$15.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.84 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.71 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.67 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.67 ,$45.38 ,
Prothrombin Time (PT) LC,151701,CDM,305,RC,85610,HCPCS,outpatient,,,$42.19 ,$14.77 ,,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$21.10 ,75,,,percent of total billed charges,75% of total billed charges,$21.10 ,75,,,percent of total billed charges,75% of total billed charges,$21.10 ,75,,,percent of total billed charges,75% of total billed charges,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$33.75 ,80,,,percent of total billed charges,80% of total billed charges,$13.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.29 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$40.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.29 ,$40.08 ,
Prothrombin Time and INR,15170,CDM,305,RC,85610,HCPCS,outpatient,,,$59.00 ,$20.65 ,,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$29.50 ,75,,,percent of total billed charges,75% of total billed charges,$29.50 ,75,,,percent of total billed charges,75% of total billed charges,$29.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$47.20 ,80,,,percent of total billed charges,80% of total billed charges,$18.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$47.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.33 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.29 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$53.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$56.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$50.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.29 ,$56.05 ,
QuantiFERON-TB Gold Plus LC,16302,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"RPR, Rfx Qn RPR/Confirm TP LC",8447849,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
RSV (Sofia),87280,CDM,300,RC,87280,HCPCS,outpatient,,,$37.11 ,$12.99 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.56 ,75,,,percent of total billed charges,75% of total billed charges,$18.56 ,75,,,percent of total billed charges,75% of total billed charges,$18.56 ,75,,,percent of total billed charges,75% of total billed charges,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.69 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.69 ,80,,,percent of total billed charges,80% of total billed charges,$11.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.55 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.42 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.73 ,$35.25 ,
Renal Pnl,16035,CDM,301,RC,80069,HCPCS,outpatient,,,$105.38 ,$36.88 ,,$11.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$52.69 ,75,,,percent of total billed charges,75% of total billed charges,$52.69 ,75,,,percent of total billed charges,75% of total billed charges,$52.69 ,75,,,percent of total billed charges,75% of total billed charges,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$84.30 ,80,,,percent of total billed charges,80% of total billed charges,$33.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.47 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$84.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.77 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.92 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.68 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$94.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$100.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.14 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$79.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$89.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.68 ,$100.11 ,
Retic Count Automated,16045,CDM,300,RC,85045,HCPCS,outpatient,,,$40.76 ,$14.27 ,,$5.28 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.28 ,100,,,fee schedule,100% Amerigroup fee schedule,$20.38 ,75,,,percent of total billed charges,75% of total billed charges,$20.38 ,75,,,percent of total billed charges,75% of total billed charges,$20.38 ,75,,,percent of total billed charges,75% of total billed charges,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$32.61 ,80,,,percent of total billed charges,80% of total billed charges,$12.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.28 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.03 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.03 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.99 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.13 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.18 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.99 ,$38.72 ,
"Reverse T3, Serum LC",8388992,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Rheumatoid Factor Qual,15175,CDM,300,RC,86430,HCPCS,outpatient,,,$108.19 ,$37.87 ,,$7.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$7.50 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.10 ,75,,,percent of total billed charges,75% of total billed charges,$54.10 ,75,,,percent of total billed charges,75% of total billed charges,$54.10 ,75,,,percent of total billed charges,75% of total billed charges,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.26 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$86.55 ,80,,,percent of total billed charges,80% of total billed charges,$34.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.50 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$86.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$75.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.20 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.14 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.28 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$102.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.28 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.35 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$91.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.14 ,$102.78 ,
"Rotavirus Ag, EIA LC",8473219,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
SARS-CoV or CoV-2 (COVID-19) Ag (Sofia),30242,CDM,300,RC,87426,HCPCS,outpatient,,,$115.00 ,$40.25 ,,$61.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$61.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.50 ,75,,,percent of total billed charges,75% of total billed charges,$57.50 ,75,,,percent of total billed charges,75% of total billed charges,$57.50 ,75,,,percent of total billed charges,75% of total billed charges,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$92.00 ,80,,,percent of total billed charges,80% of total billed charges,$36.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.33 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$103.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$109.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$35.33 ,$109.25 ,
"SARS-CoV-2 RNA (COVID-19), Qualitative NAAT QST",30242D,CDM,300,RC,87426,HCPCS,outpatient,,,$82.23 ,$28.78 ,,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$41.12 ,75,,,percent of total billed charges,75% of total billed charges,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.04 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$65.78 ,80,,,percent of total billed charges,80% of total billed charges,$26.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.99 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$35.33 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$74.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$78.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.90 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.27 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$69.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.90 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.00 ,$78.12 ,
Salicylate Level,15182,CDM,300,RC,80307,HCPCS,outpatient,,,$93.35 ,$32.67 ,,$50.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$46.68 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$74.68 ,80,,,percent of total billed charges,80% of total billed charges,$29.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$74.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$84.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$88.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$79.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.52 ,$88.68 ,
Sedimentation Rate (ESR),151833,CDM,305,RC,85651,HCPCS,outpatient,,,$133.48 ,$46.72 ,,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$106.78 ,80,,,percent of total billed charges,80% of total billed charges,$42.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$106.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$120.13 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$126.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,$126.81 ,
Sedimentation Rate (ESR) LC,15183,CDM,305,RC,85651,HCPCS,outpatient,,,$133.48 ,$46.72 ,,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.68 ,100,,,fee schedule,100% Amerigroup fee schedule,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$66.74 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$106.78 ,80,,,percent of total billed charges,80% of total billed charges,$42.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$106.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$120.13 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.80 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$126.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.59 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$113.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.27 ,$126.81 ,
"Sex Horm Binding Glob, Serum LC",8447686,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Shiga Toxin 1 and 2,16172,CDM,300,RC,87427,HCPCS,outpatient,,,$115.21 ,$40.32 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$57.61 ,75,,,percent of total billed charges,75% of total billed charges,$57.61 ,75,,,percent of total billed charges,75% of total billed charges,$57.61 ,75,,,percent of total billed charges,75% of total billed charges,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.22 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$92.17 ,80,,,percent of total billed charges,80% of total billed charges,$36.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.10 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$11.98 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$103.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$109.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$86.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$97.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$11.98 ,$109.45 ,
Smear Exam by Pathologist,16080,CDM,300,RC,85060,HCPCS,outpatient,,,$146.00 ,$51.10 ,,$27.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$27.27 ,100,,,fee schedule,100% Amerigroup fee schedule,$73.00 ,75,,,percent of total billed charges,75% of total billed charges,$73.00 ,75,,,percent of total billed charges,75% of total billed charges,$73.00 ,75,,,percent of total billed charges,75% of total billed charges,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.80 ,80,,,percent of total billed charges,80% of total billed charges,$46.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$27.27 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.97 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$45.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$131.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.76 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$138.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.49 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$109.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$124.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.49 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$25.97 ,$138.70 ,
Smear Review Criteria DC,16183,CDM,300,RC,85032,HCPCS,outpatient,,,$4.31 ,$1.51 ,,$4.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$2.16 ,75,,,percent of total billed charges,75% of total billed charges,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.40 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.45 ,80,,,percent of total billed charges,80% of total billed charges,$1.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.68 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$3.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.35 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.31 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$4.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.52 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.57 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$3.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.52 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$1.36 ,$7.03 ,
Sodium Level,15189,CDM,301,RC,84295,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$6.35 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.35 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.35 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.17 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.86 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.81 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.17 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.23 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.17 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.81 ,$31.35 ,
Sodium Level 24 Hour Urine,16250,CDM,300,RC,84300,HCPCS,outpatient,,,$46.37 ,$16.23 ,,$4.57 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.57 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$37.10 ,80,,,percent of total billed charges,80% of total billed charges,$14.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.57 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.06 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.66 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$44.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.44 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.48 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,$44.05 ,
Sodium Level Urine,15190,CDM,300,RC,84300,HCPCS,outpatient,,,$46.37 ,$16.23 ,,$4.57 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.57 ,100,,,fee schedule,100% Amerigroup fee schedule,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$23.19 ,75,,,percent of total billed charges,75% of total billed charges,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.16 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$37.10 ,80,,,percent of total billed charges,80% of total billed charges,$14.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.57 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.06 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$41.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.66 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$44.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.44 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.48 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$39.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.35 ,$44.05 ,
Specific Gravity Urine,15843,CDM,300,RC,81002,HCPCS,outpatient,,,$31.46 ,$11.01 ,,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$25.17 ,80,,,percent of total billed charges,80% of total billed charges,$9.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.48 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.17 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.27 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.21 ,$29.89 ,
Stool Culture LC,158244,CDM,306,RC,87045,HCPCS,outpatient,,,$214.00 ,$74.90 ,,$8.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$171.20 ,80,,,percent of total billed charges,80% of total billed charges,$67.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.44 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$192.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$203.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.31 ,$203.30 ,
Strep A (Revogene),15412,CDM,300,RC,87880,HCPCS,outpatient,,,$30.00 ,$10.50 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.00 ,80,,,percent of total billed charges,80% of total billed charges,$9.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.53 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.49 ,$28.50 ,
Strep A Screen,87880,CDM,300,RC,87880,HCPCS,outpatient,,,$30.00 ,$10.50 ,,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.86 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.00 ,80,,,percent of total billed charges,80% of total billed charges,$9.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.83 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.70 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.08 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.53 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.53 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$25.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.49 ,$28.50 ,
T3 Free,161044,CDM,300,RC,84481,HCPCS,outpatient,,,$238.85 ,$83.60 ,,$22.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$191.08 ,80,,,percent of total billed charges,80% of total billed charges,$75.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$191.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$183.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.30 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.94 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$214.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$226.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.73 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.94 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.94 ,$226.91 ,
T3 Uptake,15203,CDM,300,RC,84479,HCPCS,outpatient,,,$89.00 ,$31.15 ,,$8.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$44.50 ,75,,,percent of total billed charges,75% of total billed charges,$44.50 ,75,,,percent of total billed charges,75% of total billed charges,$44.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$6.60 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$71.20 ,80,,,percent of total billed charges,80% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.55 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.30 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.14 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$80.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.58 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$84.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.30 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.30 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.47 ,$84.55 ,
TSH LC,15209,CDM,301,RC,84443,HCPCS,outpatient,,,$222.14 ,$77.75 ,,$22.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$177.71 ,80,,,percent of total billed charges,80% of total billed charges,$70.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$177.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.80 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$211.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.80 ,$211.03 ,
"Tacrolimus (FK506), Blood LC/MS LC",16106,CDM,300,RC,80197,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$18.11 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.11 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$14.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.11 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.87 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.25 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.73 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.60 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.73 ,$91.20 ,
"Testosterone, Serum LC",15376,CDM,300,RC,84403,HCPCS,outpatient,,,$113.81 ,$39.83 ,,$34.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$34.09 ,100,,,fee schedule,100% Amerigroup fee schedule,$56.91 ,75,,,percent of total billed charges,75% of total billed charges,$56.91 ,75,,,percent of total billed charges,75% of total billed charges,$56.91 ,75,,,percent of total billed charges,75% of total billed charges,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.33 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$91.05 ,80,,,percent of total billed charges,80% of total billed charges,$35.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.09 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$91.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.07 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.47 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$25.81 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$102.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.21 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$108.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.12 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$85.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.44 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$96.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.12 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$25.81 ,$108.12 ,
"Testosterone,Free and Total LC",,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Therapeutic Phlebotomy,15153,CDM,940,RC,99195,HCPCS,outpatient,,,$167.93 ,$58.78 ,,$90.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.95 ,75,,,percent of total billed charges,75% of total billed charges,$125.95 ,75,,,percent of total billed charges,75% of total billed charges,$125.95 ,75,,,percent of total billed charges,75% of total billed charges,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.34 ,80,,,percent of total billed charges,80% of total billed charges,$53.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$151.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$125.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.75 ,$159.53 ,
Thyroid Antibodies LC,8388996,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Thyroid Peroxidase (TPO) Ab LC,8447652,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Thyroid Stim Immunoglobulin LC,8447724,CDM,300,RC,84445,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$51.88 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$11.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$51.37 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$50.86 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$13.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.86 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$10.86 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.65 ,$51.88 ,
Thyroid Stimulating Hormone,152092,CDM,301,RC,84443,HCPCS,outpatient,,,$222.14 ,$77.75 ,,$22.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$111.07 ,75,,,percent of total billed charges,75% of total billed charges,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.14 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$177.71 ,80,,,percent of total billed charges,80% of total billed charges,$70.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.18 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$177.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.97 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.80 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$199.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.46 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$211.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.54 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$166.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$188.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.54 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.80 ,$211.03 ,
"Thyrotropin Receptor Ab, Serum LC",8447665,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Thyroxine (T4) LC,75,CDM,300,RC,84436,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$9.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.08 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.82 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.87 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.82 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.91 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.82 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.87 ,$91.20 ,
"Thyroxine (T4), Free, Direct LC",15374,CDM,300,RC,84442,HCPCS,outpatient,,,$112.00 ,$39.20 ,,$15.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$56.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.08 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$89.60 ,80,,,percent of total billed charges,80% of total billed charges,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.36 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$89.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$14.93 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$14.78 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$100.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.02 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$106.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.07 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.63 ,$106.40 ,
Tobramycin Lvl,78,CDM,300,RC,80200,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.78 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.84 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.13 ,$71.25 ,
Tobramycin Lvl Peak,16233,CDM,300,RC,80200,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.78 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.84 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.13 ,$71.25 ,
Tobramycin Lvl Trough,16232,CDM,300,RC,80200,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$16.45 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.78 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$16.29 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.84 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.13 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.41 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.13 ,$71.25 ,
Total Iron Binding Capacity,15392,CDM,300,RC,83550,HCPCS,outpatient,,,$53.63 ,$18.77 ,,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$26.82 ,75,,,percent of total billed charges,75% of total billed charges,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.91 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$42.90 ,80,,,percent of total billed charges,80% of total billed charges,$16.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.54 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$48.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.29 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$50.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.21 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.32 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$45.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,$50.95 ,
Total T4 Level,16018,CDM,300,RC,84436,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$9.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$9.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$48.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$7.01 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.08 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.82 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$6.94 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$6.87 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.25 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.82 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.91 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.82 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$6.87 ,$91.20 ,
Transferrin,15207,CDM,300,RC,84466,HCPCS,outpatient,,,$71.00 ,$24.85 ,,$16.86 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.86 ,100,,,fee schedule,100% Amerigroup fee schedule,$35.50 ,75,,,percent of total billed charges,75% of total billed charges,$35.50 ,75,,,percent of total billed charges,75% of total billed charges,$35.50 ,75,,,percent of total billed charges,75% of total billed charges,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.02 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$56.80 ,80,,,percent of total billed charges,80% of total billed charges,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.86 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$56.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.76 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$63.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.88 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$67.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.76 ,$67.45 ,
Triglycerides,15208,CDM,301,RC,84478,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.85 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$58.40 ,80,,,percent of total billed charges,80% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.67 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.80 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.35 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.74 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$65.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$69.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.48 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.54 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.48 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.74 ,$69.35 ,
Triiodothyronine (T3) LC,8447612,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Triiodothyronine (T3), Free LC",16104,CDM,300,RC,84481,HCPCS,outpatient,,,$238.85 ,$83.60 ,,$22.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$119.43 ,75,,,percent of total billed charges,75% of total billed charges,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$17.28 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$191.08 ,80,,,percent of total billed charges,80% of total billed charges,$75.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$191.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$183.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.11 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.30 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$16.94 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$214.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$226.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.73 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$179.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.94 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$203.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$16.94 ,$226.91 ,
Troponin T LC,160164,CDM,301,RC,84484,HCPCS,outpatient,,,$168.60 ,$59.01 ,,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$134.88 ,80,,,percent of total billed charges,80% of total billed charges,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.38 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$160.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.63 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.38 ,$160.17 ,
Troponin-I,16016,CDM,301,RC,84484,HCPCS,outpatient,,,$168.60 ,$59.01 ,,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$134.88 ,80,,,percent of total billed charges,80% of total billed charges,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.38 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$160.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.63 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.38 ,$160.17 ,
Troponin-I,16016,CDM,301,RC,84484,HCPCS,outpatient,,,$168.60 ,$59.01 ,,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.00 ,100,,,fee schedule,100% Amerigroup fee schedule,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$84.30 ,75,,,percent of total billed charges,75% of total billed charges,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$12.72 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$134.88 ,80,,,percent of total billed charges,80% of total billed charges,$53.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.00 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$12.59 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.38 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$12.47 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$151.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.09 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$160.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.63 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.75 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.63 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.38 ,$160.17 ,
UA Micro,15212,CDM,300,RC,81000,HCPCS,outpatient,,,$23.60 ,$8.26 ,,$4.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$4.19 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$11.80 ,75,,,percent of total billed charges,75% of total billed charges,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.10 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.88 ,80,,,percent of total billed charges,80% of total billed charges,$7.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.19 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$18.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.07 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.06 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.99 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.02 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.19 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$22.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.07 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$20.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.07 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.99 ,$22.42 ,
Urea Nitrogen Urine,16293,CDM,300,RC,84540,HCPCS,outpatient,,,$35.13 ,$12.30 ,,$6.28 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.28 ,100,,,fee schedule,100% Amerigroup fee schedule,$17.57 ,75,,,percent of total billed charges,75% of total billed charges,$17.57 ,75,,,percent of total billed charges,75% of total billed charges,$17.57 ,75,,,percent of total billed charges,75% of total billed charges,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.67 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$28.10 ,80,,,percent of total billed charges,80% of total billed charges,$11.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.28 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.10 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.62 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.56 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.62 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.77 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$33.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.10 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.10 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.56 ,$33.37 ,
Uric Acid,152101,CDM,301,RC,84550,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$5.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.96 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.79 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.68 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.52 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.79 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.79 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.52 ,$61.82 ,
Uric Acid LC,15210,CDM,301,RC,84550,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$5.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.96 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.61 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.96 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.79 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.68 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.52 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.38 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.79 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.79 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.52 ,$61.82 ,
Urinalysis with Micro if Indicated and Culture if Indicated,16000,CDM,300,RC,81002,HCPCS,outpatient,,,$31.46 ,$11.01 ,,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$15.73 ,75,,,percent of total billed charges,75% of total billed charges,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$3.55 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$25.17 ,80,,,percent of total billed charges,80% of total billed charges,$9.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.37 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$3.51 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$3.48 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.17 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.27 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.21 ,$29.89 ,
"Urine Culture, Routine LC",158266,CDM,306,RC,87088,HCPCS,outpatient,,,$91.00 ,$31.85 ,,$10.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$45.50 ,75,,,percent of total billed charges,75% of total billed charges,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$72.80 ,80,,,percent of total billed charges,80% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.69 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.09 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$81.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.23 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$86.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.09 ,$86.45 ,
Valproic Acid Lvl,15385,CDM,300,RC,80164,HCPCS,outpatient,,,$44.33 ,$15.52 ,,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.17 ,75,,,percent of total billed charges,75% of total billed charges,$22.17 ,75,,,percent of total billed charges,75% of total billed charges,$22.17 ,75,,,percent of total billed charges,75% of total billed charges,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$35.46 ,80,,,percent of total billed charges,80% of total billed charges,$14.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.98 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$35.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.54 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$39.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.55 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$42.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$37.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.54 ,$42.11 ,
Vancomycin Lvl,15766,CDM,300,RC,80202,HCPCS,outpatient,,,$151.01 ,$52.85 ,,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$120.81 ,80,,,percent of total billed charges,80% of total billed charges,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.98 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.54 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$135.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.55 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.54 ,$143.46 ,
Vancomycin Lvl Peak,16235,CDM,300,RC,80202,HCPCS,outpatient,,,$151.01 ,$52.85 ,,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$120.81 ,80,,,percent of total billed charges,80% of total billed charges,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.98 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.54 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$135.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.55 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.54 ,$143.46 ,
Vancomycin Lvl Trough,16234,CDM,300,RC,80202,HCPCS,outpatient,,,$151.01 ,$52.85 ,,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$14.98 ,100,,,fee schedule,100% Amerigroup fee schedule,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$75.51 ,75,,,percent of total billed charges,75% of total billed charges,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$13.81 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$120.81 ,80,,,percent of total billed charges,80% of total billed charges,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.98 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$13.68 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.27 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$13.54 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$135.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.55 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$143.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.56 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.70 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$128.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$13.54 ,$143.46 ,
"Varicella-Zoster Ab, IgM LC",8447700,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Varicella-Zoster V Ab, IgG LC",8447692,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"Vitamin B1 (Thiamine), Blood LC",8447710,CDM,300,RC,84425,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$21.65 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$28.04 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$27.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.44 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$26.70 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$21.23 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$34.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$27.23 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$27.50 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,,,,,other,Not seperately reimbursable per contract terms due to charge amount,$27.23 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$21.23 ,$34.71 ,
Vitamin B12 LC,92,CDM,301,RC,82607,HCPCS,outpatient,,,$117.37 ,$41.08 ,,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$58.69 ,75,,,percent of total billed charges,75% of total billed charges,$58.69 ,75,,,percent of total billed charges,75% of total billed charges,$58.69 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$93.90 ,80,,,percent of total billed charges,80% of total billed charges,$37.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.90 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$93.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.08 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$105.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$111.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.33 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$88.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$99.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.08 ,$111.50 ,
Vitamin B12 Level,15043,CDM,301,RC,82607,HCPCS,outpatient,,,$164.16 ,$57.46 ,,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$131.33 ,80,,,percent of total billed charges,80% of total billed charges,$51.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.90 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.08 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$147.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$155.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.33 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.08 ,$155.95 ,
Vitamin B12 Level,15043E,CDM,300,RC,82607,HCPCS,outpatient,,,$164.16 ,$57.46 ,,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$131.33 ,80,,,percent of total billed charges,80% of total billed charges,$51.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.90 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.08 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$147.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$155.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.33 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.08 ,$155.95 ,
Vitamin B12 Level,82607,CDM,300,RC,82607,HCPCS,outpatient,,,$164.16 ,$57.46 ,,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$19.90 ,100,,,fee schedule,100% Amerigroup fee schedule,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.08 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$15.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$131.33 ,80,,,percent of total billed charges,80% of total billed charges,$51.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.90 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$15.23 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$15.08 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$147.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.64 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$155.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.33 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$139.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.33 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$15.08 ,$155.95 ,
Vitamin B12 and Folate LC,16141,CDM,300,RC,82747,HCPCS,outpatient,,,$30.75 ,$10.76 ,,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$22.87 ,100,,,fee schedule,100% Amerigroup fee schedule,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$15.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$18.00 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$24.60 ,80,,,percent of total billed charges,80% of total billed charges,$9.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.87 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$24.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$17.83 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.78 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$17.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$27.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.31 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$29.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.22 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.43 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$26.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.72 ,$29.21 ,
"Vitamin B6, Plasma LC",8388989,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Vitamin D 25 Hydroxy Level,15389,CDM,300,RC,82306,HCPCS,outpatient,,,$199.68 ,$69.89 ,,$39.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$39.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$99.84 ,75,,,percent of total billed charges,75% of total billed charges,$99.84 ,75,,,percent of total billed charges,75% of total billed charges,$99.84 ,75,,,percent of total billed charges,75% of total billed charges,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$30.19 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$159.74 ,80,,,percent of total billed charges,80% of total billed charges,$63.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.08 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$159.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.96 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.90 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.22 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$29.60 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$179.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.39 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$189.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.96 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.34 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$169.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.96 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$29.60 ,$189.70 ,
"Vitamin D, 25-Hydroxy LC",16324,CDM,300,RC,82652,HCPCS,outpatient,,,$258.00 ,$90.30 ,,$50.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$50.82 ,100,,,fee schedule,100% Amerigroup fee schedule,$129.00 ,75,,,percent of total billed charges,75% of total billed charges,$129.00 ,75,,,percent of total billed charges,75% of total billed charges,$129.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$39.27 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$206.40 ,80,,,percent of total billed charges,80% of total billed charges,$81.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.82 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$206.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$198.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.37 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.89 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.40 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.50 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$232.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$62.92 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$245.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.37 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$193.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$193.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$193.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.85 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$219.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.37 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$38.50 ,$245.10 ,
WBC,15012,CDM,305,RC,85048,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$3.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$2.59 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.36 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.26 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$2.57 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.20 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$2.54 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.16 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.26 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.30 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.26 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.54 ,$31.35 ,
Wet Mount,15152,CDM,306,RC,87210,HCPCS,outpatient,,,$12.00 ,$4.20 ,,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$5.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$5.94 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.60 ,80,,,percent of total billed charges,80% of total billed charges,$3.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.63 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$5.88 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.36 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$5.82 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.97 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$11.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.47 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.52 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$10.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$3.79 ,$11.40 ,
"Zinc, Plasma or Serum LC",8447604,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
CONSULTATION DIABETIC CENTER,99243,CDM,983,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
80307  PANEL DRUG SCREEN,80307,CDM,300,RC,80307,HCPCS,outpatient,,,$45.00 ,$45.00 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.50 ,75,,,percent of total billed charges,75% of total billed charges,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$63.38 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.22 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.76 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.16 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$62.14 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.51 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.99 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$14.23 ,$79.51 ,
96360 - OP IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR,963601,CDM,450,RC,96360,HCPCS,outpatient,,,$322.36 ,$112.83 ,,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$290.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.86 ,$306.24 ,
96361 HYDRATE IV INF ADDL HRS CHARGE,96361,CDM,260,RC,96361,HCPCS,outpatient,,,$70.79 ,$24.78 ,,$37.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$53.09 ,75,,,percent of total billed charges,75% of total billed charges,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.63 ,80,,,percent of total billed charges,80% of total billed charges,$22.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.80 ,$67.25 ,
96365 Iv Infusion Therapy / Prophlaxis 1st - 1 hr of Infusion,96365,CDM,260,RC,96365,HCPCS,outpatient,,,$385.00 ,$134.75 ,,$206.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$206.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$288.75 ,75,,,percent of total billed charges,75% of total billed charges,$288.75 ,75,,,percent of total billed charges,75% of total billed charges,$288.75 ,75,,,percent of total billed charges,75% of total billed charges,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.00 ,80,,,percent of total billed charges,80% of total billed charges,$121.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$134.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$308.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$296.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$119.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$346.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$77.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$365.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$308.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$288.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$327.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.08 ,$365.75 ,
96366 IV Infusion Therapy Prophlasix 2nd,96366,CDM,260,RC,96366,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96367 INFUSION IV CHARGE,96367,CDM,260,RC,96367,HCPCS,outpatient,,,$151.58 ,$53.05 ,,$81.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$113.69 ,75,,,percent of total billed charges,75% of total billed charges,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.26 ,80,,,percent of total billed charges,80% of total billed charges,$47.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$136.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$128.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.56 ,$144.00 ,
96372 IM INJ ANTIBIOTIC/THERAPEUTIC,963721,CDM,760,RC,96372,HCPCS,outpatient,,,$193.92 ,$67.87 ,,$103.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$145.44 ,75,,,percent of total billed charges,75% of total billed charges,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.14 ,80,,,percent of total billed charges,80% of total billed charges,$61.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$135.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$60.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$174.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$164.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.81 ,$184.22 ,
96372 IM OR SQ INJECTION Charge,96372,CDM,450,RC,96372,HCPCS,outpatient,,,$138.65 ,$48.53 ,,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.04 ,$131.72 ,
96374 INJ IV PUSH INITIAL,963741,CDM,760,RC,96374,HCPCS,outpatient,,,$203.50 ,$71.23 ,,$109.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$109.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.63 ,75,,,percent of total billed charges,75% of total billed charges,$152.63 ,75,,,percent of total billed charges,75% of total billed charges,$152.63 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.80 ,80,,,percent of total billed charges,80% of total billed charges,$64.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$71.23 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$162.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$142.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$63.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$183.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$152.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$172.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.68 ,$193.33 ,
96375 INJECT IV SEQ Charge OBS,96375,CDM,760,RC,96375,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
99219 INITIAL OBSERV-CARE LEVEL 2 - ONCOLOGY CHARGE,99219,CDM,983,RC,99219,HCPCS,outpatient,,,$333.00 ,$116.55 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
99220 INITIAL OBSERV-CARE LEVEL 3 - ONCOLOGY CHARGE,99220,CDM,983,RC,99220,HCPCS,outpatient,,,$456.00 ,$159.60 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
IV INFUSION THEAPY/PROPHLAXIS 1ST - 1HR,963651,CDM,760,RC,96365,HCPCS,outpatient,,,$195.00 ,$68.25 ,,$104.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$146.25 ,75,,,percent of total billed charges,75% of total billed charges,$146.25 ,75,,,percent of total billed charges,75% of total billed charges,$146.25 ,75,,,percent of total billed charges,75% of total billed charges,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.00 ,80,,,percent of total billed charges,80% of total billed charges,$61.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$68.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$136.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$150.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$60.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$175.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$185.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$146.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$146.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$146.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.03 ,$185.25 ,
Blood Culture,15828,CDM,306,RC,87040,HCPCS,outpatient,,,$77.94 ,$27.28 ,,$13.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$13.63 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.97 ,75,,,percent of total billed charges,75% of total billed charges,$38.97 ,75,,,percent of total billed charges,75% of total billed charges,$38.97 ,75,,,percent of total billed charges,75% of total billed charges,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.53 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$62.35 ,80,,,percent of total billed charges,80% of total billed charges,$24.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.63 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$62.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$10.42 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.98 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$10.32 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$70.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.87 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$74.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.37 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$66.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$10.32 ,$74.04 ,
Body Fluid Culture,150341,CDM,306,RC,87071,HCPCS,outpatient,,,$223.68 ,$78.29 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$178.94 ,80,,,percent of total billed charges,80% of total billed charges,$70.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$201.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$212.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$212.50 ,
Catheter Tip Culture,150342,CDM,306,RC,87071,HCPCS,outpatient,,,$233.00 ,$81.55 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$116.50 ,75,,,percent of total billed charges,75% of total billed charges,$116.50 ,75,,,percent of total billed charges,75% of total billed charges,$116.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$186.40 ,80,,,percent of total billed charges,80% of total billed charges,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$186.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$209.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$221.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$174.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$198.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$221.35 ,
Cerebrospinal Fluid Culture,16269,CDM,306,RC,87071,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$103.55 ,
Ear Culture,16270,CDM,306,RC,87071,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$70.00 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$133.00 ,
Eye Culture,16271,CDM,306,RC,87071,HCPCS,outpatient,,,$453.00 ,$158.55 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$226.50 ,75,,,percent of total billed charges,75% of total billed charges,$226.50 ,75,,,percent of total billed charges,75% of total billed charges,$226.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$362.40 ,80,,,percent of total billed charges,80% of total billed charges,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$362.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$317.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$348.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$407.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$430.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$430.35 ,
Genital Culture,16272,CDM,306,RC,87071,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$54.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$103.55 ,
Gram Stain Report,15113,CDM,306,RC,87205,HCPCS,outpatient,,,$37.18 ,$13.01 ,,$3.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$3.10 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$18.59 ,75,,,percent of total billed charges,75% of total billed charges,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$4.36 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$29.74 ,80,,,percent of total billed charges,80% of total billed charges,$11.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.10 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$29.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.01 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$4.31 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.95 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$4.27 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$33.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.84 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$35.32 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.01 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.04 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$31.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.01 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$2.95 ,$35.32 ,
JDHS AST-GN67,150331,CDM,306,RC,87186,HCPCS,outpatient,,,$25.74 ,$9.01 ,,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$20.59 ,80,,,percent of total billed charges,80% of total billed charges,$8.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.13 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.14 ,$24.45 ,
JDHS AST-GP67,150333,CDM,306,RC,87186,HCPCS,outpatient,,,$25.74 ,$9.01 ,,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$20.59 ,80,,,percent of total billed charges,80% of total billed charges,$8.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.13 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.14 ,$24.45 ,
JDHS AST-ST02,15033,CDM,306,RC,87186,HCPCS,outpatient,,,$25.74 ,$9.01 ,,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$20.59 ,80,,,percent of total billed charges,80% of total billed charges,$8.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$23.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.13 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$24.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$21.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.14 ,$24.45 ,
JDHS-GN95,150333,CDM,306,RC,87186,HCPCS,outpatient,,,$36.00 ,$12.60 ,,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$11.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.82 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$28.80 ,80,,,percent of total billed charges,80% of total billed charges,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.41 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.74 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.65 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$32.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.13 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$34.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.09 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.20 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.65 ,$34.20 ,
Nasal Culture,150344,CDM,306,RC,87071,HCPCS,outpatient,,,$223.68 ,$78.29 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$178.94 ,80,,,percent of total billed charges,80% of total billed charges,$70.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$201.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$212.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$212.50 ,
Sputum Culture,150346,CDM,306,RC,87071,HCPCS,outpatient,,,$314.27 ,$109.99 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$157.14 ,75,,,percent of total billed charges,75% of total billed charges,$157.14 ,75,,,percent of total billed charges,75% of total billed charges,$157.14 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$251.42 ,80,,,percent of total billed charges,80% of total billed charges,$99.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$251.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$219.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$241.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$282.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$298.56 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$251.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$235.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$235.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$235.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$267.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$298.56 ,
Stool Culture,15824,CDM,306,RC,87045,HCPCS,outpatient,,,$214.00 ,$74.90 ,,$8.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$8.31 ,100,,,fee schedule,100% Amerigroup fee schedule,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$107.00 ,75,,,percent of total billed charges,75% of total billed charges,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$9.63 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$171.20 ,80,,,percent of total billed charges,80% of total billed charges,$67.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.53 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.44 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$192.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$203.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$181.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.31 ,$203.30 ,
Throat Culture,16273,CDM,306,RC,87071,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$61.82 ,
Tissue Culture,15034,CDM,306,RC,87071,HCPCS,outpatient,,,$223.68 ,$78.29 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$111.84 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$178.94 ,80,,,percent of total billed charges,80% of total billed charges,$70.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$201.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$212.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$190.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$212.50 ,
Urine Culture,15826,CDM,306,RC,87088,HCPCS,outpatient,,,$65.07 ,$22.77 ,,$10.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$10.69 ,100,,,fee schedule,100% Amerigroup fee schedule,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$32.54 ,75,,,percent of total billed charges,75% of total billed charges,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$8.25 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$52.06 ,80,,,percent of total billed charges,80% of total billed charges,$20.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.69 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$8.17 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.18 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$8.09 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$58.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.23 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$61.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.38 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.49 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$55.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$8.09 ,$61.82 ,
Wound Culture,16274,CDM,306,RC,87071,HCPCS,outpatient,,,$153.15 ,$53.60 ,,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$6.23 ,100,,,fee schedule,100% Amerigroup fee schedule,$76.58 ,75,,,percent of total billed charges,75% of total billed charges,$76.58 ,75,,,percent of total billed charges,75% of total billed charges,$76.58 ,75,,,percent of total billed charges,75% of total billed charges,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$10.09 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$122.52 ,80,,,percent of total billed charges,80% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.23 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$9.99 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$9.89 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$137.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.71 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$145.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.05 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.05 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$5.93 ,$145.49 ,
11000 MD DEBRIDE UP TO 10 % BSA CHARGE,28749,CDM,361,RC,11000,HCPCS,outpatient,,,"$1,267.00 ",$443.45 ,,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$443.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$975.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$392.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,140.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,203.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,178.31 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$247.07 ,"$1,203.65 ",
203120 CENTRAL VENOUS PLACEMENT,203120,CDM,370,RC,36556,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
22096 LUMBAR PUNCTURE,22096,CDM,360,RC,62270,HCPCS,outpatient,,,$551.00 ,$192.85 ,,$295.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$295.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$413.25 ,75,,,percent of total billed charges,75% of total billed charges,$413.25 ,75,,,percent of total billed charges,75% of total billed charges,$413.25 ,75,,,percent of total billed charges,75% of total billed charges,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$440.80 ,80,,,percent of total billed charges,80% of total billed charges,$174.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$192.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$440.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$424.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$170.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$495.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$110.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$523.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$440.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$512.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$413.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$413.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$413.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$468.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.45 ,$523.45 ,
32560 INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS CHARGE,32560,CDM,450,RC,32560,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
7046 INTUBATION,7046,CDM,410,RC,31500,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
90791 PSYCHIATRIC EVALUATION (NO MED SERVICES),8119857,CDM,900,RC,90791,HCPCS,outpatient,,,$381.00 ,$133.35 ,,$204.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$204.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$304.80 ,80,,,percent of total billed charges,80% of total billed charges,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$133.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$304.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$266.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$293.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$118.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$342.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$76.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.30 ,$361.95 ,
90832 FAMILY THERAPY W / PATIENT 30 MIN,10527320,CDM,916,RC,90832,HCPCS,outpatient,,,$177.00 ,$61.95 ,,$94.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.75 ,75,,,percent of total billed charges,75% of total billed charges,$132.75 ,75,,,percent of total billed charges,75% of total billed charges,$132.75 ,75,,,percent of total billed charges,75% of total billed charges,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.60 ,80,,,percent of total billed charges,80% of total billed charges,$55.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$136.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$159.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$168.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$150.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.52 ,$168.15 ,
90832 PSYC TX 30 MIN IND OP (16-27 MIN),8119861,CDM,914,RC,90832,HCPCS,outpatient,,,$217.00 ,$75.95 ,,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$195.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.32 ,$206.15 ,
90834 INDV PSYCHOTHERAPY 38-52 MIN,9584193,CDM,914,RC,90834,HCPCS,outpatient,,,$299.00 ,$104.65 ,,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$104.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$92.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$269.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$284.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.31 ,$284.05 ,
90837 INDIVIDUAL THERAPY 53 - 67 MINS,10527335,CDM,914,RC,90837,HCPCS,outpatient,,,$381.00 ,$133.35 ,,$204.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$204.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$285.75 ,75,,,percent of total billed charges,75% of total billed charges,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$304.80 ,80,,,percent of total billed charges,80% of total billed charges,$120.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$133.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$304.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$266.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$293.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$118.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$342.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$76.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$323.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.30 ,$361.95 ,
90839 PSYCHOTHERAPY - FOR CRISIS - FIRST 60 M CHARGE,9601171,CDM,914,RC,90839,HCPCS,outpatient,,,$326.00 ,$114.10 ,,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$251.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.57 ,$309.70 ,
90846 FAMILY PSYCHOTHERAPY W/OUT PATIENT PRESENT,9584191,CDM,916,RC,90846,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.04 ,$258.40 ,
90847 FAMILY PSYCHOTHERAPY W/ PATIENT PRESENT,8119868,CDM,916,RC,90847,HCPCS,outpatient,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
90847 FAMILY THERAPY W / PATIENT 1HR,10527319,CDM,916,RC,90847,HCPCS,outpatient,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
90853 GROUP PSYCHOTHERAPY,8119870,CDM,915,RC,90853,HCPCS,outpatient,,,$326.00 ,$114.10 ,,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$251.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.57 ,$309.70 ,
97605 FOS PRESSURE WOUND THERAPY 97605 CHARGE,28807,CDM,510,RC,97605,HCPCS,outpatient,,,$615.39 ,$215.39 ,,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$215.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$473.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$553.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$584.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$572.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.00 ,$584.62 ,
"99199 No Charge, Special Services",28612,CDM,999,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99201 OFFICE/OP VISIT NEW-1 CHARGE,28820,CDM,510,RC,99201,HCPCS,outpatient,,,$245.00 ,$85.75 ,,$131.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$183.75 ,75,,,percent of total billed charges,75% of total billed charges,$183.75 ,75,,,percent of total billed charges,75% of total billed charges,$183.75 ,75,,,percent of total billed charges,75% of total billed charges,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.00 ,80,,,percent of total billed charges,80% of total billed charges,$77.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$85.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$188.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$75.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$220.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$232.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$208.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.78 ,$232.75 ,
99202 OFFICE/OP VISIT NEW-2 CHARGE Tech,28821,CDM,510,RC,99202,HCPCS,outpatient,,,$472.00 ,$165.20 ,,$252.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$354.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.00 ,75,,,percent of total billed charges,75% of total billed charges,$354.00 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$377.60 ,80,,,percent of total billed charges,80% of total billed charges,$149.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$165.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$330.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$363.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$424.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$94.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$448.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$377.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$401.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.04 ,$448.40 ,
99203 OFFICE/OP VISIT NEW-3 CHARGE,28822,CDM,510,RC,99203,HCPCS,outpatient,,,$308.00 ,$107.80 ,,$165.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$231.00 ,75,,,percent of total billed charges,75% of total billed charges,$231.00 ,75,,,percent of total billed charges,75% of total billed charges,$231.00 ,75,,,percent of total billed charges,75% of total billed charges,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.40 ,80,,,percent of total billed charges,80% of total billed charges,$97.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$107.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$215.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$237.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$95.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$277.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$61.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$292.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$286.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$261.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.06 ,$292.60 ,
99204 OFFICE/OP VISIT NEW-4 CHARGE,28823,CDM,510,RC,99204,HCPCS,outpatient,,,$475.00 ,$166.25 ,,$254.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$254.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$356.25 ,75,,,percent of total billed charges,75% of total billed charges,$356.25 ,75,,,percent of total billed charges,75% of total billed charges,$356.25 ,75,,,percent of total billed charges,75% of total billed charges,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$380.00 ,80,,,percent of total billed charges,80% of total billed charges,$150.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$166.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$380.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$332.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$332.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$365.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$147.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$427.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$451.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$380.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$441.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$403.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.63 ,$451.25 ,
99211 OFFICE/OP VISIT EST-1 CHARGE,28825,CDM,510,RC,99211,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.79 ,$115.90 ,
99212 Office Visit Established Pt. Level 2 (SP Pro),28826,CDM,510,RC,99212,HCPCS,outpatient,,,$175.18 ,$61.31 ,,$93.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.39 ,75,,,percent of total billed charges,75% of total billed charges,$131.39 ,75,,,percent of total billed charges,75% of total billed charges,$131.39 ,75,,,percent of total billed charges,75% of total billed charges,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.14 ,80,,,percent of total billed charges,80% of total billed charges,$55.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.16 ,$166.42 ,
99213 Office Visit Established Pt. Level 3 (SP Pro),28827,CDM,510,RC,99213,HCPCS,outpatient,,,$302.08 ,$105.73 ,,$161.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$161.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$226.56 ,75,,,percent of total billed charges,75% of total billed charges,$226.56 ,75,,,percent of total billed charges,75% of total billed charges,$226.56 ,75,,,percent of total billed charges,75% of total billed charges,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.66 ,80,,,percent of total billed charges,80% of total billed charges,$95.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$105.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$211.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$93.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$271.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$286.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$256.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.91 ,$286.98 ,
99214 OFFICE/OP VISIT EST-4 CHARGE,28828,CDM,761,RC,99214,HCPCS,outpatient,,,$223.08 ,$78.08 ,,$119.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$167.31 ,75,,,percent of total billed charges,75% of total billed charges,$167.31 ,75,,,percent of total billed charges,75% of total billed charges,$167.31 ,75,,,percent of total billed charges,75% of total billed charges,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.46 ,80,,,percent of total billed charges,80% of total billed charges,$70.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$171.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$69.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$200.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$211.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.50 ,$211.93 ,
99215 Level Five Follow-Up,28829,CDM,510,RC,99215,HCPCS,outpatient,,,$944.64 ,$330.62 ,,$506.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$506.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$708.48 ,75,,,percent of total billed charges,75% of total billed charges,$708.48 ,75,,,percent of total billed charges,75% of total billed charges,$708.48 ,75,,,percent of total billed charges,75% of total billed charges,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$755.71 ,80,,,percent of total billed charges,80% of total billed charges,$298.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$330.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$755.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$661.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$727.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$292.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$850.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$189.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$897.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$878.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$802.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.20 ,$897.41 ,
99422 INDIVIDUAL TELE 11 - 20 MIN,10528994,CDM,914,RC,99422,HCPCS,outpatient,,,$217.00 ,$75.95 ,,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$195.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.32 ,$206.15 ,
99423 INDIVIDUAL TELE 21> MIN,10528995,CDM,914,RC,99423,HCPCS,outpatient,,,$299.00 ,$104.65 ,,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$104.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$92.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$269.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$284.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.31 ,$284.05 ,
DRESSING TEGADERM 4X5.,12824,CDM,270,RC,,HCPCS,outpatient,,,$48.00 ,$16.80 ,,$25.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.40 ,80,,,percent of total billed charges,80% of total billed charges,$15.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.36 ,$45.60 ,
G0463 HOSPITAL OUTPATIENT CLINIC VISIT,28830,CDM,510,RC,G0463,HCPCS,outpatient,,,$295.00 ,$103.25 ,,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$103.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$265.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.53 ,$280.25 ,
G2012 INDIVIDUAL TELE,10527336,CDM,914,RC,,HCPCS,outpatient,,,$299.00 ,$104.65 ,,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$104.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$92.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$269.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$284.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.31 ,$284.05 ,
Misc Radiology Charge,MISCRAD,CDM,999,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Office Visit new 60 mins,28824,CDM,982,RC,,HCPCS,outpatient,,,$600.00 ,$210.00 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
"Closed treatment of vertebral body fracture(s) without manipulation, requiring and including casting",301181,CDM,270,RC,,HCPCS,outpatient,,,$383.00 ,$134.05 ,,$205.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$205.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$287.25 ,75,,,percent of total billed charges,75% of total billed charges,$287.25 ,75,,,percent of total billed charges,75% of total billed charges,$287.25 ,75,,,percent of total billed charges,75% of total billed charges,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.40 ,80,,,percent of total billed charges,80% of total billed charges,$121.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$134.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$268.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$118.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$344.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$76.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$363.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$356.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$287.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$287.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$287.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$325.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.69 ,$363.85 ,
"Unlisted procedure, casting or strapping 29799",301191,CDM,270,RC,,HCPCS,outpatient,,,$365.00 ,$127.75 ,,$195.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$195.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$273.75 ,75,,,percent of total billed charges,75% of total billed charges,$273.75 ,75,,,percent of total billed charges,75% of total billed charges,$273.75 ,75,,,percent of total billed charges,75% of total billed charges,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$292.00 ,80,,,percent of total billed charges,80% of total billed charges,$115.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$127.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$292.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$281.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$113.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$328.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$73.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$346.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$273.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$273.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$310.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.18 ,$346.75 ,
AMBULATORY EEG 24 HR,95953,CDM,740,RC,95953,HCPCS,outpatient,,,"$1,762.00 ",$616.70 ,,$944.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$944.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,409.60 ",80,,,percent of total billed charges,80% of total billed charges,$557.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$616.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,409.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,233.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,233.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,356.74 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$551.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$343.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$546.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,585.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$353.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,673.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,409.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$350.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,638.66 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,321.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$353.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,497.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$343.59 ,"$1,673.90 ",
"Electroencephalogram (EEG) extended monitoring, greater than 1 hour 95813",95813,CDM,740,RC,95813,HCPCS,outpatient,,,$761.00 ,$266.35 ,,$407.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$407.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$570.75 ,75,,,percent of total billed charges,75% of total billed charges,$570.75 ,75,,,percent of total billed charges,75% of total billed charges,$570.75 ,75,,,percent of total billed charges,75% of total billed charges,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$608.80 ,80,,,percent of total billed charges,80% of total billed charges,$240.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$266.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$608.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$532.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$585.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$235.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$684.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$722.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$608.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$151.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$707.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$570.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$570.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$570.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$646.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.40 ,$722.95 ,
"Electroencephalogram (EEG), including recording awake and drowsy 95816",95816,CDM,740,RC,95816,HCPCS,outpatient,,,$710.00 ,$248.50 ,,$380.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$380.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$532.50 ,75,,,percent of total billed charges,75% of total billed charges,$532.50 ,75,,,percent of total billed charges,75% of total billed charges,$532.50 ,75,,,percent of total billed charges,75% of total billed charges,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$568.00 ,80,,,percent of total billed charges,80% of total billed charges,$224.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$248.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$568.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$497.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$497.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$546.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$222.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$220.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$639.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$142.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$674.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$568.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$660.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$532.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$532.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$532.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$603.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.45 ,$674.50 ,
"Electroencephalogram (EEG), all night recording 95827",95827,CDM,740,RC,95827,HCPCS,outpatient,,,"$1,225.00 ",$428.75 ,,$656.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$656.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$918.75 ,75,,,percent of total billed charges,75% of total billed charges,$918.75 ,75,,,percent of total billed charges,75% of total billed charges,$918.75 ,75,,,percent of total billed charges,75% of total billed charges,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$980.00 ,80,,,percent of total billed charges,80% of total billed charges,$387.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$428.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$980.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$857.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$857.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$943.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$383.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$379.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,102.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,163.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$980.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$243.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,139.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$918.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$918.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$918.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,041.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.88 ,"$1,163.75 ",
"Electroencephalogram, including recording awake and asleep 95819",95819,CDM,740,RC,95819,HCPCS,outpatient,,,$845.00 ,$295.75 ,,$452.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$452.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$633.75 ,75,,,percent of total billed charges,75% of total billed charges,$633.75 ,75,,,percent of total billed charges,75% of total billed charges,$633.75 ,75,,,percent of total billed charges,75% of total billed charges,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$676.00 ,80,,,percent of total billed charges,80% of total billed charges,$267.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$295.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$676.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$591.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$591.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$650.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$264.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$261.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$760.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$169.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$802.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$676.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$168.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$785.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$633.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$633.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$633.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$169.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$718.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.78 ,$802.75 ,
10061 I & D COMPLEX/MULTI CHARGE,28745,CDM,361,RC,10061,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11721 DEBRIDE NAIL 6 OR MORE CHARGE,11721,CDM,450,RC,11721,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11740 DRAIN BLOOD UNDER NA CHARGE,117400,CDM,983,RC,11740,HCPCS,outpatient,,,$98.00 ,$34.30 ,,$29.41 ,100,,,fee schedule,100% Amerigroup fee schedule,$29.41 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$32.06 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$30.00 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$29.41 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$30.29 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$30.00 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$30.29 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$30.00 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$29.41 ,$32.06 ,
16020 BURN CARE SMALL <5% CHARGE,28793,CDM,361,RC,16020,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
20600 INJ/DRAIN SM JT CHARGE,12856,CDM,983,RC,20600,HCPCS,outpatient,,,$228.00 ,$79.80 ,,$48.97 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.97 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$53.38 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.95 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.97 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$50.44 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.95 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$50.44 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$49.95 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$48.97 ,$53.38 ,
20605 INJ/DRAIN INTERM JT CHARGE,12857,CDM,983,RC,20605,HCPCS,outpatient,,,$228.00 ,$79.80 ,,$54.08 ,100,,,fee schedule,100% Amerigroup fee schedule,$54.08 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.95 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$55.16 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$54.08 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$55.70 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$55.16 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$55.70 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$55.16 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$54.08 ,$58.95 ,
20610 Arthrocentesis injection into large joints or Bursa without UltraSound Tech,12859,CDM,250,RC,20610,HCPCS,outpatient,,,$228.00 ,$79.80 ,,$122.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$171.00 ,75,,,percent of total billed charges,75% of total billed charges,$171.00 ,75,,,percent of total billed charges,75% of total billed charges,$171.00 ,75,,,percent of total billed charges,75% of total billed charges,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.40 ,80,,,percent of total billed charges,80% of total billed charges,$72.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$205.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$216.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$171.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$171.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$171.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.46 ,$216.60 ,
29105 SPLINT LONG ARM CHARGE,28798,CDM,510,RC,29105,HCPCS,outpatient,,,$351.00 ,$122.85 ,,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$270.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$333.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.45 ,$333.45 ,
29125 SPLINT SHORT ARM CHARGE,22075,CDM,450,RC,29125,HCPCS,outpatient,,,$50.00 ,$17.50 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,$47.50 ,
29505 SPLINT LONG LEG CHARGE,5011,CDM,450,RC,29505,HCPCS,outpatient,,,$124.00 ,$43.40 ,,$66.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.00 ,75,,,percent of total billed charges,75% of total billed charges,$93.00 ,75,,,percent of total billed charges,75% of total billed charges,$93.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.20 ,80,,,percent of total billed charges,80% of total billed charges,$39.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$95.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$111.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$105.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.18 ,$117.80 ,
29515 SPLINT SHORT LEG CHARGE,5012,CDM,450,RC,29515,HCPCS,outpatient,,,$110.00 ,$38.50 ,,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.45 ,$104.50 ,
32554 THORACENTESIS CHARGE,22085,CDM,361,RC,32554,HCPCS,outpatient,,,$570.00 ,$199.50 ,,$305.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$305.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$427.50 ,75,,,percent of total billed charges,75% of total billed charges,$427.50 ,75,,,percent of total billed charges,75% of total billed charges,$427.50 ,75,,,percent of total billed charges,75% of total billed charges,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$456.00 ,80,,,percent of total billed charges,80% of total billed charges,$180.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$199.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$456.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$399.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$399.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$438.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$176.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$513.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$114.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$541.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$456.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$427.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$427.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$427.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$484.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$111.15 ,$541.50 ,
"36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, W/ SUBCU. PORT OR PUMP, CNTRL OR PRPH, INSER",20389,CDM,323,RC,36590,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
49082 ABD PARACENTESIS W/O GUIDANCE CHARGE,16025,CDM,361,RC,49082,HCPCS,outpatient,,,"$1,134.00 ",$396.90 ,,$607.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$607.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$907.20 ,80,,,percent of total billed charges,80% of total billed charges,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$396.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$793.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$793.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$873.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$351.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,020.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$227.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,077.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,054.62 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.13 ,"$1,077.30 ",
53899 UNLISTED UROLOGY PROCEDURE,53899,CDM,450,RC,53899,HCPCS,outpatient,,,$110.00 ,$38.50 ,,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.45 ,$104.50 ,
64400 NERVE BLOCK TRIGEMIN CHARGE,12866,CDM,983,RC,64400,HCPCS,outpatient,,,$373.00 ,$130.55 ,,$79.24 ,100,,,fee schedule,100% Amerigroup fee schedule,$79.24 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$86.37 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$80.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$79.24 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$81.62 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$80.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$81.62 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$80.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$79.24 ,$86.37 ,
69200 REMOVE FB  EAR CHARGE,69200,CDM,983,RC,69200,HCPCS,outpatient,,,$167.00 ,$58.45 ,,$52.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$52.36 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$57.07 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$53.41 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$52.36 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$53.93 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$53.41 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$53.93 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$53.41 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$52.36 ,$57.07 ,
69210 REMOVE IMPACTED EAR WAX UNI CHARGE,69210,CDM,450,RC,69210,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
96360 IV HYDRATION 1ST HR CHARGE,263516,CDM,760,RC,96360,HCPCS,outpatient,,,$206.57 ,$72.30 ,,$110.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$154.93 ,75,,,percent of total billed charges,75% of total billed charges,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.26 ,80,,,percent of total billed charges,80% of total billed charges,$65.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$185.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.28 ,$196.24 ,
96368 IV CONCURRENT INFUSION CHARGE,20274,CDM,260,RC,96368,HCPCS,outpatient,,,$231.99 ,$81.20 ,,$124.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$173.99 ,75,,,percent of total billed charges,75% of total billed charges,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.59 ,80,,,percent of total billed charges,80% of total billed charges,$73.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$197.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.24 ,$220.39 ,
96376 IV PUSH SEQUENTIAL SAME DRUG CHARGE,20272,CDM,260,RC,96376,HCPCS,outpatient,,,$85.80 ,$30.03 ,,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$64.35 ,75,,,percent of total billed charges,75% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges,$27.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.73 ,$81.51 ,
99292 CRITICAL CARE ADDL 30 MIN HOSP CHARGE,99292,CDM,983,RC,99292,HCPCS,outpatient,,,$298.00 ,$104.30 ,,$81.55 ,100,,,fee schedule,100% Amerigroup fee schedule,$81.55 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$88.89 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$83.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$81.55 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$84.00 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$83.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$84.00 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$83.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$81.55 ,$88.89 ,
Group Therapy Provided,8123863,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
OT Group Therapy Assistant Units,28578A,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
OT Group Therapy Units,8123863,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
OT Low Complex Units,8123903,CDM,420,RC,97165,HCPCS,outpatient,,,$200.00 ,$70.00 ,,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$180.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.00 ,$190.00 ,
OT Moderate Complex Units,8123905,CDM,420,RC,97166,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
OT Swallow Eval Charge,8123901,CDM,444,RC,92610,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
97112 NEURO RE-EDUCATION Charge,10526268,CDM,420,RC,97112,HCPCS,outpatient,,,$61.00 ,$21.35 ,,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,$57.95 ,
97124 MASSAGE Charge,10526266,CDM,420,RC,97124,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
"97165 OT EVAL, LOW COMPLEXITY",9859392,CDM,420,RC,97165,HCPCS,outpatient,,,$200.00 ,$70.00 ,,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$180.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.00 ,$190.00 ,
"97166 OT EVAL, MOD COMPLEXITY",9859395,CDM,420,RC,97166,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
99205 Office new visit 60 min,992051,CDM,982,RC,99205,HCPCS,outpatient,,,$950.00 ,$332.50 ,,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$149.46 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$137.12 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$137.12 ,$149.46 ,
99213 Office Visit Established Pt. Level 3,992131,CDM,982,RC,,HCPCS,outpatient,,,$450.00 ,$157.50 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
99214 Office Visit Established Pt. Level 4,,CDM,982,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99215 Office Visit Established 40 mins,99215,CDM,982,RC,99215,HCPCS,outpatient,,,$692.40 ,$242.34 ,,$93.46 ,100,,,fee schedule,100% Amerigroup fee schedule,$93.46 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.87 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$93.46 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$96.26 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$96.26 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$93.46 ,$101.87 ,
10060 I&D ABSCESS SIMPLE OF SINGLE CHARGE,28744,CDM,361,RC,10060,HCPCS,outpatient,,,$420.48 ,$147.17 ,,$225.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$315.36 ,75,,,percent of total billed charges,75% of total billed charges,$315.36 ,75,,,percent of total billed charges,75% of total billed charges,$315.36 ,75,,,percent of total billed charges,75% of total billed charges,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$336.38 ,80,,,percent of total billed charges,80% of total billed charges,$132.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$147.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$336.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$323.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$130.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$378.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$84.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$399.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$315.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$315.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$315.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$357.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.99 ,$399.46 ,
10120 INC & REM FB SQ SMPL CHARGE,28746,CDM,361,RC,10120,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
10160 PUNCTURE DRAIN LESION CHARGE,28748,CDM,361,RC,10160,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11042 OP 761 DEBRIDEMENT SKIN & SUBCUTANEOUS TIS CHARGE,28750,CDM,361,RC,11042,HCPCS,outpatient,,,"$1,133.84 ",$396.84 ,,$607.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$607.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$850.38 ,75,,,percent of total billed charges,75% of total billed charges,$850.38 ,75,,,percent of total billed charges,75% of total billed charges,$850.38 ,75,,,percent of total billed charges,75% of total billed charges,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$907.07 ,80,,,percent of total billed charges,80% of total billed charges,$358.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$396.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$793.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$793.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$873.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$355.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$355.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$351.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,020.46 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$227.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,077.15 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$225.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,054.47 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$850.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$963.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.10 ,"$1,077.15 ",
11043 DEBRIDE SKIN SUBCUT TISSUE MUSCLE CHARGE,28751,CDM,361,RC,11043,HCPCS,outpatient,,,"$1,216.32 ",$425.71 ,,$651.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$651.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$912.24 ,75,,,percent of total billed charges,75% of total billed charges,$912.24 ,75,,,percent of total billed charges,75% of total billed charges,$912.24 ,75,,,percent of total billed charges,75% of total billed charges,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$973.06 ,80,,,percent of total billed charges,80% of total billed charges,$384.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$425.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$973.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$851.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$851.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$936.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$380.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$377.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,094.69 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$244.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,155.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$973.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$241.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,131.18 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$912.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$912.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$912.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,033.87 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.18 ,"$1,155.50 ",
11044 DEBRIDE SKIN SUBCUT TISSUE MUSCLE CHARGE,28752,CDM,361,RC,11044,HCPCS,outpatient,,,"$3,360.96 ","$1,176.34 ",,"$1,801.47 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,801.47 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,688.77 ",80,,,percent of total billed charges,80% of total billed charges,"$1,062.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,176.34 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,688.77 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,352.67 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,352.67 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,587.94 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$668.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,052.32 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$655.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,041.90 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,024.86 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$674.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,192.91 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,688.77 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$668.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,125.69 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,520.72 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$674.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,856.82 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$668.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$655.39 ,"$3,192.91 ",
11045 DEBRIDE SKIN EA ADDTL CHARGE,28753,CDM,361,RC,11045,HCPCS,outpatient,,,$553.57 ,$193.75 ,,$296.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$296.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$415.18 ,75,,,percent of total billed charges,75% of total billed charges,$415.18 ,75,,,percent of total billed charges,75% of total billed charges,$415.18 ,75,,,percent of total billed charges,75% of total billed charges,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.86 ,80,,,percent of total billed charges,80% of total billed charges,$175.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$193.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$387.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$387.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$426.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$173.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$173.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$171.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$498.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$111.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$525.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$514.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$415.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$415.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$415.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$470.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.95 ,$525.89 ,
11046 DEBRIDE MUSCLE FASCIA EA ADDTL CHARGE,28754,CDM,361,RC,11046,HCPCS,outpatient,,,$856.00 ,$299.60 ,,$458.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$458.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$642.00 ,75,,,percent of total billed charges,75% of total billed charges,$642.00 ,75,,,percent of total billed charges,75% of total billed charges,$642.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$684.80 ,80,,,percent of total billed charges,80% of total billed charges,$270.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$299.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$684.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$599.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$659.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$265.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$770.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$171.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$813.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$796.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$642.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$642.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$642.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$171.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$727.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$166.92 ,$813.20 ,
11047 DEBRIDE BONE EA ADDTL CHARGE,28755,CDM,361,RC,11047,HCPCS,outpatient,,,"$1,525.00 ",$533.75 ,,$817.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$817.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,220.00 ",80,,,percent of total billed charges,80% of total billed charges,$482.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$533.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,220.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,067.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,174.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$477.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$472.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,372.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$306.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,448.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,220.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$303.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,418.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,143.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$306.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.38 ,"$1,448.75 ",
11104 PUNCH BIOPSY SKIN SINGLE LESION CHARGE,20306,CDM,361,RC,11104,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11106 INCISIONAL BIOPSY SKIN SINGLE LESION CHARGE,28758,CDM,361,RC,11106,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11107 INCISIONAL BIOPSY SKIN EA SEP/ADDL LSN CHARGE,28759,CDM,361,RC,11107,HCPCS,outpatient,,,$412.00 ,$144.20 ,,$220.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$220.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$329.60 ,80,,,percent of total billed charges,80% of total billed charges,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$144.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$329.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$288.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$317.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$370.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$391.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$329.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.34 ,$391.40 ,
11401 REMOVE SKIN LESION CHARGE,28760,CDM,361,RC,11401,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11730 AVULSION OF NAIL PLATE PARTIAL/COMP CHARGE,28768,CDM,361,RC,11730,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
11750 REMOVAL NAIL BED CHARGE,11750,CDM,361,RC,11750,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
12001 REPAIR SIMPLE <=2.5 CM CHARGE,28770,CDM,361,RC,12001,HCPCS,outpatient,,,$313.17 ,$109.61 ,,$167.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$167.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.88 ,75,,,percent of total billed charges,75% of total billed charges,$234.88 ,75,,,percent of total billed charges,75% of total billed charges,$234.88 ,75,,,percent of total billed charges,75% of total billed charges,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$250.54 ,80,,,percent of total billed charges,80% of total billed charges,$99.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$109.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$219.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$241.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$97.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$281.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$62.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$234.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$234.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$234.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.07 ,$297.51 ,
12011 REPAIR-SIMPLE FACE EARS <=2.5 CM CHARGE,28772,CDM,361,RC,12011,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
12020 TX SUPERFICAL WOUND SIMPLE CLOSURE CHARGE,28774,CDM,361,RC,12020,HCPCS,outpatient,,,"$1,267.00 ",$443.45 ,,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$443.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$975.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$392.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,140.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,203.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,178.31 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$247.07 ,"$1,203.65 ",
12031 REPAIR-INTERMEDIATE <=2.5 CM CHARGE,28775,CDM,361,RC,12031,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
12032 INTMD WOUND REPAIR S/TR/EXT 2.6-7.5 CM CHARGE,28776,CDM,361,RC,12032,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
13160 SECONDARY CLOSURE OF SURGICAL WOUND CHARGE,20266,CDM,510,RC,13160,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
15271 APP SKN SUB GRFT T/A/L AREA/100SQ CM CHARGE,28784,CDM,761,RC,15271,HCPCS,outpatient,,,"$2,795.71 ",$978.50 ,,"$1,498.50 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,498.50 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,236.57 ",80,,,percent of total billed charges,80% of total billed charges,$884.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$978.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,236.57 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,957.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,957.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,152.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$875.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$866.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,516.14 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$561.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,655.92 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,236.57 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$556.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,600.01 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,096.78 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$561.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,376.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$545.16 ,"$2,655.92 ",
16000 INIT TX 1ST DEGR BURN CHARGE,28792,CDM,361,RC,16000,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
20220 BIOPSY BONE TROCAR OR NEEDLE SUPERFICAL CHARGE,28796,CDM,361,RC,20220,HCPCS,outpatient,,,"$3,501.00 ","$1,225.35 ",,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,225.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,695.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,085.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,150.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,325.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,255.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$682.70 ,"$3,325.95 ",
20240 OPEN SUPERFIC BONE BX CHARGE,28899,CDM,361,RC,20240,HCPCS,outpatient,,,"$6,038.00 ","$2,113.30 ",,"$3,236.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,236.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,113.30 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,226.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,226.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,649.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,177.41 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,871.78 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,434.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,212.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,736.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,615.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,212.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,177.41 ","$5,736.10 ",
29125 SHORT ARM SPLINT (FORE TO HAND) STAT CHARGE,28799,CDM,510,RC,29125,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.04 ,$258.40 ,
29445 APPLICATION RIGID TOTAL CONTACT LEG CAST CHARGE,28800,CDM,510,RC,29445,HCPCS,outpatient,,,$616.00 ,$215.60 ,,$330.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$330.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$462.00 ,75,,,percent of total billed charges,75% of total billed charges,$462.00 ,75,,,percent of total billed charges,75% of total billed charges,$462.00 ,75,,,percent of total billed charges,75% of total billed charges,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$492.80 ,80,,,percent of total billed charges,80% of total billed charges,$194.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$215.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$492.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$431.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$474.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$554.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$585.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$572.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$523.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.12 ,$585.20 ,
36589 REMOVAL TUNNELED CV CATH CHARGE,28904,CDM,361,RC,36589,HCPCS,outpatient,,,"$1,590.00 ",$556.50 ,,$852.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$852.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$556.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,113.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,113.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,224.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$492.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,431.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$319.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,510.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,478.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$319.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$310.05 ,"$1,510.50 ",
97597 WOUND DRESSING WITH DEBRIDEMENT- COMPLEX CHARGE,28804,CDM,361,RC,97597,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
CASE CANCELLED,28615,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
97164 PT ReEval Units,9438785,CDM,424,RC,97164,HCPCS,outpatient,,,$91.00 ,$31.85 ,,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$81.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.75 ,$86.45 ,
ADL Training Charge,8111715,CDM,420,RC,97535,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
Gait Training Charges,8111691,CDM,420,RC,97116,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.53 ,$36.68 ,
Iontophoresis Charges,8111685,CDM,420,RC,97033,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.26 ,$103.55 ,
Manual Therapy Charge Units,8111688,CDM,420,RC,97140,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
Mechanical Traction Charge,8111701,CDM,420,RC,97012,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
Neuromuscular Reeducation Charges,8111697,CDM,420,RC,97112,HCPCS,outpatient,,,$61.00 ,$21.35 ,,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,$57.95 ,
PT ADL Training Assitant Units,30180A,CDM,420,RC,97535,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
PT Canalith Repositioning Charge,8111752,CDM,420,RC,95992,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Canalith Repositioning Assist Units,28576A,CDM,420,RC,95992,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Gait Training Assistant Units,28582A,CDM,420,RC,97116,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.53 ,$36.68 ,
PT Gait Training Assistant Units,28582,CDM,420,RC,97116,HCPCS,outpatient,,,$38.61 ,$13.51 ,,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$28.96 ,75,,,percent of total billed charges,75% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges,$12.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.53 ,$36.68 ,
PT Group Therapy Assitant Units,28579A,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
PT High Complex Units,8111852,CDM,424,RC,97163,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
PT Iontophhoresis Assistant Units,28587A,CDM,420,RC,97033,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.26 ,$103.55 ,
PT Low Complex Units,8111848,CDM,424,RC,97161,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
PT Manual Therapy Assistant Units,28581A,CDM,420,RC,97140,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Massage Assistant Units,28590A,CDM,420,RC,97124,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Massage Charge Units,1042079,CDM,420,RC,97124,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Mechanical Traction Units,8111701,CDM,420,RC,97012,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Mechanical Traction Assistant Units,28586A,CDM,420,RC,97012,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Moderate Complex Units,8111850,CDM,424,RC,97162,HCPCS,outpatient,,,$113.69 ,$39.79 ,,$60.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.27 ,75,,,percent of total billed charges,75% of total billed charges,$85.27 ,75,,,percent of total billed charges,75% of total billed charges,$85.27 ,75,,,percent of total billed charges,75% of total billed charges,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.95 ,80,,,percent of total billed charges,80% of total billed charges,$35.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$102.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$108.01 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$85.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.17 ,$108.01 ,
PT Neuromuscular Reeducation Assist Unit,28577A,CDM,420,RC,97112,HCPCS,outpatient,,,$61.00 ,$21.35 ,,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.75 ,75,,,percent of total billed charges,75% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges,$19.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,$57.95 ,
PT Paraffin Assistant Units,28589A,CDM,420,RC,97018,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
PT ReEval Units,8111855,CDM,424,RC,97164,HCPCS,outpatient,,,$91.00 ,$31.85 ,,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$68.25 ,75,,,percent of total billed charges,75% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges,$28.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$81.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.75 ,$86.45 ,
PT Therapeutic Activity Assistant Units,28583A,CDM,420,RC,97530,HCPCS,outpatient,,,$89.00 ,$31.15 ,,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.36 ,$84.55 ,
PT Therapeutic Exercise Assit Units,28580A,CDM,420,RC,97110,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$65.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.24 ,$69.35 ,
PT Ultrasound Assistant Units,28585A,CDM,420,RC,97035,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Unattended E-Stim Units,1366412,CDM,420,RC,97014,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
PT Unattended E-Stim Assistant Units,28584A,CDM,420,RC,97014,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
Paraffin Bath Charge,1366285,CDM,420,RC,97018,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
Therapeutic Activities Charge,8111693,CDM,420,RC,97530,HCPCS,outpatient,,,$89.00 ,$31.15 ,,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.36 ,$84.55 ,
Therapeutic Exercise Charges,8111702,CDM,420,RC,97110,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$65.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.24 ,$69.35 ,
Ultrasound Charges,8111698,CDM,420,RC,97035,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
Unattended Electrical Therapy Charge,1366412,CDM,420,RC,97014,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
10021-Aspiration Fine Needle w/o Imaging,10021,CDM,450,RC,10021,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
10060-I&D Abscess/Cyst/Hematoma Simple,10060,CDM,450,RC,10060,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
10061-I&D Abscess/Cyst/Hematoma Complicated,10061,CDM,450,RC,10061,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
10080-I&D Pilonidal Cyst Simple,10080,CDM,450,RC,10080,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
10081-I&D Pilonidal Cyst Complicated,10081,CDM,450,RC,10081,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
10120-Subcutaneous Tissue Simple,10120,CDM,450,RC,10120,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
10121-Subcutaneous Tissue Complex,10121,CDM,450,RC,10121,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
10140-I&D Hematoma/Seroma/Fluid,10140,CDM,450,RC,10140,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
10160-Aspiration Abscess/Cyst/Hematoma,10160,CDM,450,RC,10160,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
10180-I&D Postop Wound Infection Complex,10180,CDM,450,RC,10180,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
11000-Extensive Eczematous/Infected Skin Less Than 10%,11000,CDM,450,RC,11000,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11001-Extensive Eczematous/Infected Skin Each Additional 10%,11001,CDM,450,RC,11001,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11010-FB Skin/Subsequent of Open Fracture/Dislocation Site,11010,CDM,450,RC,11010,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11011 - Foreign Material open fracture/dislocation,11011,CDM,450,RC,11011,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11042-SQ Tissue Less Than/Equal to 1st 20 sq cm,11042,CDM,450,RC,11042,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11043-SQ Tissue/Muscle Less Than/Equal to 1st 20 sq cm,11043,CDM,450,RC,11043,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"11044 - Bone, first 20 cm or less",11044,CDM,450,RC,11044,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11045 - Subcutaneous Tissue,11045,CDM,450,RC,11045,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11046 - Muscle and/or fascia,11046,CDM,450,RC,11046,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
11047 - Bone,11047,CDM,450,RC,11047,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11055-Paring/Cut Lesion Benign Single,11055,CDM,450,RC,11055,HCPCS,outpatient,,,$174.00 ,$60.90 ,,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$60.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$53.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$156.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.93 ,$165.30 ,
11056 - Paring/Cutting Benign Lesion,11056,CDM,450,RC,11056,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11200-Removal Skin Tag up to 15,11200,CDM,450,RC,11200,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
11305-Shave Lesion Scalp/Hand/Feet/Genital <= 0.5 cm,11305,CDM,450,RC,11305,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11400-Excision Lesion Benign Trunk/Extremity <= 0.5 cm,11400,CDM,450,RC,11400,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
11402-Excision Lesion Benign Trunk/Extremity 1.1-2.0 cm,11402,CDM,450,RC,11402,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11420-Excise Lesion BN Scalp/Nose/Hand/Feet/Genital <=0.5 cm,11420,CDM,450,RC,11420,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11421 - Excision benign s/n/h/f 0.6 - 1 cm,11421,CDM,450,RC,11421,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11426 - Exision benign s/n/h/f > 4 cm,11426,CDM,450,RC,11426,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
11440-Excise Lesion Benign Face Less Than/Equal to 0.5 cm,11440,CDM,450,RC,11440,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11443 - Excision benign f/e/e/n/l 2.1 - 3 cm,11443,CDM,450,RC,11443,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11719-Trimming Nails Nondystrophic,11719,CDM,450,RC,11719,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11720-Nails 1 to 5,11720,CDM,450,RC,11720,HCPCS,outpatient,,,$135.00 ,$47.25 ,,$72.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$101.25 ,75,,,percent of total billed charges,75% of total billed charges,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.00 ,80,,,percent of total billed charges,80% of total billed charges,$42.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$47.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$94.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$103.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$121.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$128.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$101.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.33 ,$128.25 ,
11721-Nails 6 or More,11721,CDM,450,RC,11721,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
11730-Avulsion Nail Plate Single,11730,CDM,450,RC,11730,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
11732-Avulsion Nail Plate Each Addl,11732,CDM,450,RC,11732,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
11740-Evacuation Subungual Hematoma,11740,CDM,450,RC,11740,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
11750-Excision Nail & Matrix,11750,CDM,450,RC,11750,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11760-Repair of Nail Bed,11760,CDM,450,RC,11760,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
11762 - Reconstruction nail bed w graft ,11762,CDM,450,RC,11762,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
11765-Wedge Excision Skin Nail Fold,11765,CDM,450,RC,11765,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
11976-Contraceptive Capsule,11976,CDM,450,RC,11976,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
12001-Scalp/Neck/Trunk/Genital/Extremity <= 2.5 cm,28770,CDM,450,RC,12001,HCPCS,outpatient,,,$615.39 ,$215.39 ,,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$329.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$461.54 ,75,,,percent of total billed charges,75% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges,$194.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$215.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$430.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$473.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$553.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$584.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$572.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$523.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.00 ,$584.62 ,
12002-Scalp/Neck/Trunk/Genital/Extremity 2.6-7.5 cm,12002,CDM,450,RC,12002,HCPCS,outpatient,,,$227.61 ,$79.66 ,,$122.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$170.71 ,75,,,percent of total billed charges,75% of total billed charges,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.09 ,80,,,percent of total billed charges,80% of total billed charges,$71.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$204.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$216.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.38 ,$216.23 ,
12004-Scalp/Neck/Trunk/Genital/Extremity 7.6-12.5 cm,12004,CDM,450,RC,12004,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12005-Scalp/Neck/Trunk/Genital/Extremity 12.6-20.0 cm,12005,CDM,450,RC,12005,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12006-Scalp/Neck/Trunk/Genital/Extremity 20.1-30 cm,12006,CDM,450,RC,12006,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12007-Scalp/Neck/Trunk/Genital/Extremity Greater Than 30 cm,12007,CDM,450,RC,12007,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12011-Face/Ear/Eyelid/Nose/Lip Less Than/Equal to 2.5 cm,12011,CDM,450,RC,12011,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
12013-Face/Ear/Eyelid/Nose/Lip 2.6-5.0 cm,12013,CDM,450,RC,12013,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12014-Face/Ear/Eyelid/Nose/Lip 5.1-7.5 cm,12014,CDM,450,RC,12014,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12015-Face/Ear/Eyelid/Nose/Lip 7.6-12.5 cm,12015,CDM,450,RC,12015,HCPCS,outpatient,,,$162.00 ,$56.70 ,,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$121.50 ,75,,,percent of total billed charges,75% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges,$51.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.59 ,$153.90 ,
12016-Face/Ear/Eyelid/Nose/Lip 12.6-20.0 cm,12016,CDM,450,RC,12016,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12017-Face/Ear/Eyelid/Nose/Lip 20.1-30.0 cm,12017,CDM,450,RC,12017,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
12018-Face/Ear/Eyelid/Nose/Lip Greater Than 30.0 cm,12018,CDM,450,RC,12018,HCPCS,outpatient,,,$163.00 ,$57.05 ,,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.79 ,$154.85 ,
12020-Treatment Superficial Wound Dehiscence,12020,CDM,450,RC,12020,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
12021-Superficial Dehiscence w/packing,12021,CDM,450,RC,12021,HCPCS,outpatient,,,$163.00 ,$57.05 ,,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.79 ,$154.85 ,
12031-Scalp/Trunk/Extremity Less Than/Equal to 2.5 cm,12031,CDM,450,RC,12031,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
12032-Scalp/Trunk/Extremity 2.6-7.5cm,12032,CDM,450,RC,12032,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12034-Scalp/Trunk/Extremity 7.6-12.5 cm,12034,CDM,450,RC,12034,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12035-Scalp/Trunk/Extremity 12.6-20.0 cm,12035,CDM,450,RC,12035,HCPCS,outpatient,,,$230.00 ,$80.50 ,,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.85 ,$218.50 ,
12036-Scalp/Trunk/Extremity 20.1-30.0 cm,12036,CDM,450,RC,12036,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12037-Scalp/Trunk/Extremity Greater Than 30.0 cm,12037,CDM,450,RC,12037,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12041-Neck/Hand/Feet/Genital Less Than/Equal to 2.5 cm,12041,CDM,450,RC,12041,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12042-Neck/Hand/Feet/Genital 2.6-7.5 cm,12042,CDM,450,RC,12042,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
12044-Neck/Hand/Feet/Genital 7.6-12.5 cm,12044,CDM,450,RC,12044,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12045-Neck/Hand/Feet/Genital 12.6-20.0 cm,12045,CDM,450,RC,12045,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12046-Neck/Hand/Feet/Genital 20.1-30.0 cm,12046,CDM,450,RC,12046,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12047-Neck/Hand/Feet/Genital Greater Than 30.0 cm,12047,CDM,450,RC,12047,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12051-Face/Ear/Eye/Nose/Lip Less Than/Equal to 2.5 cm,12051,CDM,450,RC,12051,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12052-Face/Ear/Eye/Nose/Lip 2.6-5.0 cm,12052,CDM,450,RC,12052,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12053-Face/Ear/Eye/Nose/Lip 5.1-7.5 cm,12053,CDM,450,RC,12053,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12054-Face/Ear/Eye/Nose/Lip 7.6-12.5 cm,12054,CDM,450,RC,12054,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12055-Face/Ear/Eye/Nose/Lip 12.6-20.0 cm,12055,CDM,450,RC,12055,HCPCS,outpatient,,,$350.00 ,$122.50 ,,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$262.50 ,75,,,percent of total billed charges,75% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges,$110.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.25 ,$332.50 ,
12056-Face/Ear/Eye/Nose/Lip 20.1-30.0 cm,12056,CDM,450,RC,12056,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
12057-Face/Ear/Eye/Nose/Lip Greater Than 30.0 cm,12057,CDM,450,RC,12057,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13100-Trunk 1.1-2.5 cm,13100,CDM,450,RC,13100,HCPCS,outpatient,,,$360.00 ,$126.00 ,,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$270.00 ,75,,,percent of total billed charges,75% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges,$113.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.20 ,$342.00 ,
13101-Trunk 2.6-7.5 cm,13101,CDM,450,RC,13101,HCPCS,outpatient,,,$189.00 ,$66.15 ,,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.75 ,75,,,percent of total billed charges,75% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges,$59.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$170.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.86 ,$179.55 ,
13102-Trunk Each Addl 5 cm,13102,CDM,450,RC,13102,HCPCS,outpatient,,,$230.00 ,$80.50 ,,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.85 ,$218.50 ,
13120-Scalp/Arms/Legs 1.1-2.5 cm,13120,CDM,450,RC,13120,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
13121-Scalp/Arms/Legs 2.6-7.5 cm,13121,CDM,450,RC,13121,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13122-Scalp/Arms/Legs Each Addl 5 cm,13122,CDM,450,RC,13122,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13131-Face/Neck/Hand/Feet/Genital 1.1-2.5 cm,13131,CDM,450,RC,13131,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13132-Face/Neck/Hand/Feet/Genital 2.6-7.5 cm,13132,CDM,450,RC,13132,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13133-Face/Neck/Hand/Feet/Genital Each Addl 5 cm,13133,CDM,450,RC,13133,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13150-Eyes/Ears/Nose/Lips 1.0 cm or Less,13150,CDM,450,RC,13150,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13151-Eyes/Ears/Nose/Lip 1.1-2.5 cm,13151,CDM,450,RC,13151,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13152-Eye/Ear/Nose/Lip 2.6-7.5 cm,13152,CDM,450,RC,13152,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
13153-Eye/Ear/Nose/Lip Each Addl 5 cm,13153,CDM,450,RC,13153,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
14040-Transfer Tissue Head/Hand/Feet Less Than/Equal to 10 cm,14040,CDM,450,RC,14040,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
15240-Full thickness graft 20 sq cm/less,15240,CDM,450,RC,15240,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
16000-Initial Treatment First Degree Burn,16000,CDM,450,RC,16000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
16020-Burn Dressings/Debridement Small,16020,CDM,450,RC,16020,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
16025-Burn Dressings/Debridement Medium,16025,CDM,450,RC,16025,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
16030-Burn Dressings/Debridement Large,16030,CDM,450,RC,16030,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
17110 - Destruction benign; up to 14,17110,CDM,450,RC,17110,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
17250-Chemical Cauterization Granulation Tissue,17250,CDM,450,RC,17250,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
19020-Mastotomy Exploration/Drain Abscess Deep,19020,CDM,450,RC,19020,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
20100 - Exploration of penetrating wound; neck,20100,CDM,450,RC,20100,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20102-Explore Penetrating Wound Abd/Back,20102,CDM,450,RC,20102,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
20103-Explore Penetrating Wound Extremity,20103,CDM,450,RC,20103,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
20501 - Injections of Sinus Tract,20501,CDM,450,RC,20501,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20520-Removal Body Muscle Sheath; Simple,20520,CDM,450,RC,20520,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
20525-Remove foreign body in muscle;deep,20525,CDM,450,RC,20525,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
20550 - Inj single tendon/ligament,20550,CDM,450,RC,20550,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
20552-Inject Trigger Point 1-2 Muscles,20552,CDM,450,RC,20552,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20553 - Injection Trigger Point 3 or More Muscles,20553,CDM,450,RC,20553,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20600-Small Joint Aspirate/Inject w/o US,20600,CDM,450,RC,20600,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
20604 - Arthrocentesis Aspiration/Inj w/US,20604,CDM,450,RC,20604,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20605-Intermediate Aspiration/Inj w/o US,20605,CDM,450,RC,20605,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
20606 - Arthrocentesis Aspiration/Inj w/US,20606,CDM,450,RC,20606,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20610-Major Joint Aspirate/Inject w/o US,20610,CDM,450,RC,20610,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
20611 - Arthrocentesis Aspiration/Inj w/US,20611,CDM,450,RC,20611,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20612-Aspiration/Injection Ganglion Cyst,20612,CDM,450,RC,20612,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
20615-Aspiration/Injection Bone Cyst,20615,CDM,450,RC,20615,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
20670 - Implant; superficial,20670,CDM,450,RC,20670,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
20950 - Monitor Inter fluid pressure,20950,CDM,450,RC,20950,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
21315 - Nasal Bone Fx w/o Stabilization,21315,CDM,450,RC,21315,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
21320-Nasal Bone w/ Stabilization,21320,CDM,450,RC,21320,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
21450-Clsd Tx mandibularfracturew/omanip,21450,CDM,450,RC,21450,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
21451-Clsd Tx mandibularfracture w/manip,21451,CDM,450,RC,21451,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
21480-Temporomandibular/Jaw,21480,CDM,450,RC,21480,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
"21501 - I&D, deep abscess or hematoma",21501,CDM,450,RC,21501,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
23330 - Removal Foreign Body in Shoulder,23330,CDM,450,RC,23330,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
23500 - Clavicular w/o manipulation,23500,CDM,450,RC,23500,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
23570 - Scapular w/o manipulation,23570,CDM,450,RC,23570,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
23600 - Proximal Humeral w/o manipulation,23600,CDM,450,RC,23600,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
23605-Proximal Humeral w/ Manipulation,23605,CDM,450,RC,23605,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
23650-Shoulder w/o Anesthesia,23650,CDM,450,RC,23650,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
23655-Shoulder w/ Anesthesia,23655,CDM,450,RC,23655,HCPCS,outpatient,,,$850.00 ,$297.50 ,,$455.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$455.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$637.50 ,75,,,percent of total billed charges,75% of total billed charges,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$680.00 ,80,,,percent of total billed charges,80% of total billed charges,$268.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$297.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$595.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$654.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$263.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$765.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$170.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$807.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$637.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$722.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.75 ,$807.50 ,
23665-Shoulder Dislocation w/ Humeral Fx,23665,CDM,450,RC,23665,HCPCS,outpatient,,,$800.00 ,$280.00 ,,$428.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$428.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$600.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$640.00 ,80,,,percent of total billed charges,80% of total billed charges,$252.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$280.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$640.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$560.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$616.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$248.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$720.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$160.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$760.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$640.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$680.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.00 ,$760.00 ,
23675 - Shoulder dis w/manip,23675,CDM,450,RC,23675,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
23931-I&D Elbow Abscess/Bursa/Hematoma,21501,CDM,450,RC,23931,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24200-Upper Arm/Elbow Subcutaneous,24200,CDM,450,RC,24200,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
24201 - Upper Arm/Elbow Deep,24201,CDM,450,RC,24201,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
24500 - Humeral Shaft Fracture w/o Manipulation,24500,CDM,450,RC,24500,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
24505-Humeral Shaft w/ Manipulation,24505,CDM,450,RC,24505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
24530 - Supracondylar/Transcondylar Humoral,24530,CDM,450,RC,24530,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24577-Humeral Condylar w/ Manipulation,24577,CDM,450,RC,24577,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24600-Elbow w/o Anesthesia,24600,CDM,450,RC,24600,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24605-Elbow w/ Anesthesia,24605,CDM,450,RC,24605,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24620-Elbow/ Monteggia w/ Manipulation,24620,CDM,450,RC,24620,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
24640-Nursemaid Elbow,24640,CDM,450,RC,24640,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24650 - Radial Head/Neck w/o manipulation,24650,CDM,450,RC,24650,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
24655 - Radial Head/Neck w/ Manipulation,24655,CDM,450,RC,24655,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
24670 - Ulnar Proximal End w/o manipulation,24670,CDM,450,RC,24670,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
24675-Ulna Proximal End w/ Manipulation,24675,CDM,450,RC,24675,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"24999 - Unlisted Procedures, humerus/elbow",24999,CDM,450,RC,24999,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
"25248 - Exploration, forearm/wrist",25248,CDM,450,RC,25248,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
25500-Radial Shaft w/o Manipulation,25500,CDM,450,RC,25500,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25505-Radial Shaft w/ Manipulation,25505,CDM,450,RC,25505,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25530 - Ulnar Shaft w/o manipulation,25530,CDM,450,RC,25530,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25535-Ulnar Shaft w/ Manipulation,25535,CDM,450,RC,25535,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25560-Radial & Ulnar Shaft w/o Manipulation,25560,CDM,450,RC,25560,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25565-Radial&Ulnar Shaft w/ Manipulation,25565,CDM,450,RC,25565,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25600-Distal Radial w/o Manipulation,25600,CDM,450,RC,25600,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25605-Distal Radial w/ Manipulation,25605,CDM,450,RC,25605,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25622 - Carpal Scaphoid w/o manipulation,25622,CDM,450,RC,25622,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25630 - Carpal Bone w/o manipulation,25630,CDM,450,RC,25630,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25650 - Closed Tx Ulnar Styloid fracture,25650,CDM,450,RC,25650,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
25660-Radiocarpal/Intercarpal Dislocation w/ Manipulation,25660,CDM,450,RC,25660,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
25675-Clsd Treat Distal Radioulnar Disloc w/ Manip,25675,CDM,450,RC,25675,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
25690-Lunate w/ Manipulation,25690,CDM,450,RC,25690,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26010-I&D Finger Abscess Simple,26010,CDM,450,RC,26010,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
26011-I&D Finger Abscess Complicated,26011,CDM,450,RC,26011,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
"26123-Fasciectomy, single finger",26123,CDM,450,RC,26123,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
"26236 - Partial excision bone, finger",26236,CDM,450,RC,26236,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
26350 - Repair Flexor Tendon,26350,CDM,450,RC,26350,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
26418 - Repair finger w/o graft,26418,CDM,450,RC,26418,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
26600 - Clsd Tx metacarpal fracture w/o manip,26600,CDM,450,RC,26600,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
26605-Metacarpal w/ Manipulation,26605,CDM,450,RC,26605,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26641-Carpometacarpal Thumb,26641,CDM,450,RC,26641,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26670-Carpometacarpal Other Than Thumb,26670,CDM,450,RC,26670,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
26700-Metacarpophalangeal/Knuckle,26700,CDM,450,RC,26700,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26705 - Metacarp w/manip & anesthesia,26705,CDM,450,RC,26705,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
26720-Phalanx Shaft w/o Manipulation,26720,CDM,450,RC,26720,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
26725-Phalanx Shaft w/ Manipulation,26725,CDM,450,RC,26725,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26727 - Phalanx Shaft w/ Manipulation,26727,CDM,450,RC,26727,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26742-Metacarpophalangeal/Interphalangeal Joint w/ Manip,26742,CDM,450,RC,26742,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26750-Distal Phalangeal w/o manipulation,26750,CDM,450,RC,26750,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26755-Distal Phalangeal w/ Manipulation,26755,CDM,450,RC,26755,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
26765-Distal Phalangeal Open,26765,CDM,450,RC,26765,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
26770-Interphalangeal Hand w/o Anesthesia,26770,CDM,450,RC,26770,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
26775-Interphalangeal Hand w/ Anesthesia,26775,CDM,450,RC,26775,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26951-Partial Amputation of Long Finger,26951,CDM,450,RC,26951,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
26952 - Amputation finger or thumb,26952,CDM,450,RC,26952,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"26989 - Unlisted procedure, hands/fingers",26989,CDM,450,RC,26989,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
27197 - Posterior Pelvis Ring w/o manipulation,27197,CDM,450,RC,27197,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
27220 - Acetabulum w/o manipulation,27220,CDM,450,RC,27220,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
27222 - Clsd Tx hip socket w/manip,27222,CDM,450,RC,27222,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27230 - Femoral Proximal End/Neck w/o manipulation,27230,CDM,450,RC,27230,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27232 - Clsd Tx femoral fracture w/manip,27232,CDM,450,RC,27232,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
27238 - Clsd Tx femoral fracture w/o manip,27238,CDM,450,RC,27238,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27244 - Femoral Fracture w/ plate/screw implant,27244,CDM,450,RC,27244,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27246 - Greater Trochanteric w/o manipulation,27246,CDM,450,RC,27246,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27250-Hip Traumatic w/o Anesthesia,27250,CDM,450,RC,27250,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27252 - Hip Traumatic w/ Anesthesia,27252,CDM,450,RC,27252,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27256 - Spontaneous Hip w/o Anesthesia,72756,CDM,450,RC,27256,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27257 - Hip w/ Manipulation & Anesthesia,27257,CDM,450,RC,27257,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
27265-Hip Post Arthroplasty,27265,CDM,450,RC,27265,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
27266-Hip Post Arthroplasty w/Anesthesia,27266,CDM,450,RC,27266,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
27301-I&D Thigh/Knee Abscess/Bursa/Hematoma,27301,CDM,450,RC,27301,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
27500 - Femoral Shaft w/o manipulation,27500,CDM,450,RC,27500,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27502-Femoral Shaft w/ Manipulation,27502,CDM,450,RC,27502,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27510-Femoral Distal w/ Manipulation,27510,CDM,450,RC,27510,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27520 - Patellar w/o Manipulation,27520,CDM,450,RC,27520,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27550-Knee w/o Anesthesia,27550,CDM,450,RC,27550,HCPCS,outpatient,,,$169.00 ,$59.15 ,,$90.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$126.75 ,75,,,percent of total billed charges,75% of total billed charges,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.20 ,80,,,percent of total billed charges,80% of total billed charges,$53.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$152.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$143.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.96 ,$160.55 ,
27552-Knee w/ Anesthesia,27552,CDM,450,RC,27552,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
27560-Patellar w/o Anesthesia,27560,CDM,450,RC,27560,HCPCS,outpatient,,,$142.00 ,$49.70 ,,$76.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.50 ,75,,,percent of total billed charges,75% of total billed charges,$106.50 ,75,,,percent of total billed charges,75% of total billed charges,$106.50 ,75,,,percent of total billed charges,75% of total billed charges,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.60 ,80,,,percent of total billed charges,80% of total billed charges,$44.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$99.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$109.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$127.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$134.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$106.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$120.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.69 ,$134.90 ,
27562-Patella w/anethesia,27562,CDM,450,RC,27562,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
"27599 - Unlisted Procedure, Femur/Knee",27599,CDM,450,RC,27599,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
27650 - Repair Ruptured Achilles tendon,27650,CDM,450,RC,27650,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27750 - Tibial Shaft w/o manipulation,27750,CDM,450,RC,27750,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27752-Tibial Shaft w/ Manipulation,27752,CDM,450,RC,27752,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27760 - Medial Malleolus w/o manipulation,27760,CDM,450,RC,27760,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27762-Medial Malleolus w/ Manipulation,27762,CDM,450,RC,27762,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27768-Posterior Malleolus w/ Manipulation,27768,CDM,450,RC,27768,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27786-Distal Fibular w/o Manipulation,27786,CDM,450,RC,27786,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27788-Distal Fibular w/ Manipulation,27788,CDM,450,RC,27788,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
27808-Bimalleolar Ankle w/o Manipulation,27808,CDM,450,RC,27808,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27810-Bimalleolar Ankle w/ Manipulation,27810,CDM,450,RC,27810,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27816 - Trimalleolar Ankle w/o manipulation,27816,CDM,450,RC,27816,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
27818-Trimalleolar Ankle w/ Manipulation,27818,CDM,450,RC,27818,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
27825-Distal Tibia w/ Traction or Manipulation,27825,CDM,450,RC,27825,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
27840-Ankle w/o Anesthesia,27840,CDM,450,RC,27840,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
27842 - Ankle w/ Anesthesia,27842,CDM,450,RC,27842,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
28190-Foot Subcutaneous,28190,CDM,450,RC,28190,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
28192 - Foot Deep,28192,CDM,450,RC,28192,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28193 - Foot Complicated,28193,CDM,450,RC,28193,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
28400 - Calcaneal w/o manipulation,28400,CDM,450,RC,28400,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
28430 - Talus w/o manipulation,28430,CDM,450,RC,28430,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
28435-Talus w/ Manipulation,28435,CDM,450,RC,28435,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28470 - Metatarsal w/o manipulation,28470,CDM,450,RC,28470,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
28475 - Metatarsal w/manipulation,28475,CDM,450,RC,28475,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
28490-Great Toe/Phalanges w/o manip,28490,CDM,450,RC,28490,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
28495-Great Toe w/ Manipulation,28495,CDM,450,RC,28495,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
28510-Phalanx w/o Manipulation; Not Great Toe,28510,CDM,450,RC,28510,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
28515-Phalanx w/ Manipulation; Not Great Toe,28515,CDM,450,RC,28515,HCPCS,outpatient,,,$133.00 ,$46.55 ,,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$99.75 ,75,,,percent of total billed charges,75% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges,$42.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$119.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.94 ,$126.35 ,
28540 - Clsd Tx tarsal w/o anesthesia,28540,CDM,450,RC,28540,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
28545-Tarsal Bone w/anethesia,28545,CDM,450,RC,28545,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28600 - Tarsometatarsal w/o Anesthesia,28600,CDM,450,RC,28600,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28630-Metatarsophalangeal w/o Anesthesia,28630,CDM,450,RC,28630,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
28660-Interphalangeal Foot w/o Anesthesia,28660,CDM,450,RC,28660,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
"29049 - Cast Application,Figure-of-Eight",29049,CDM,450,RC,29049,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29065-Application cast shoulder to hand (long arm),29065,CDM,450,RC,29065,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
29075-Cast Application Elbow to Finger (short arm),29075,CDM,450,RC,29075,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
29085-App cast hand and lower forearm (gauntlet),29085,CDM,450,RC,29085,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
29105-Long Arm,29105,CDM,450,RC,29105,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29125-Short Arm,29125,CDM,450,RC,29125,HCPCS,outpatient,,,$50.00 ,$17.50 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,$47.50 ,
29126 - Short Arm (Forearm to Hand),29126,CDM,450,RC,29126,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29130-Finger,29130,CDM,450,RC,29130,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29131 - Application of Finger Splint; dynamic,29131,CDM,450,RC,29131,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29240 - Strapping of Shoulder,29240,CDM,450,RC,29240,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
29280 - Strapping of Hand or Finger,29280,CDM,450,RC,29280,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
29345-Application of long leg cast thigh to toes,29345,CDM,450,RC,29345,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29405-App of Short Leg Cast (below knee to toes),29405,CDM,450,RC,29405,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
29425 - Application Short Leg Cast,29425,CDM,450,RC,29425,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
29505-Long Leg,29505,CDM,450,RC,29505,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
29515-Short Leg,29515,CDM,450,RC,29515,HCPCS,outpatient,,,$110.00 ,$38.50 ,,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$82.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges,$34.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.45 ,$104.50 ,
29530 - Strapping of Knee,29530,CDM,450,RC,29530,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
"29540-Strapping of lower leg, ankle, and/or foot",29540,CDM,450,RC,29540,HCPCS,outpatient,,,$65.00 ,$22.75 ,,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$58.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.68 ,$61.75 ,
29550-Strapping Toes,29550,CDM,450,RC,29550,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
29580-Strapping Unna Boot,29580,CDM,450,RC,29580,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
29705-Remove/Bivalving Cast Full Arm/Leg,29705,CDM,450,RC,29705,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
29799 - Unlisted proc/cast/strap,29799,CDM,450,RC,29799,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
30000-Drainage Nasal Abscess/Hematoma,30000,CDM,450,RC,30000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
30020-Drainage Nasal Septum Abscess/Hematoma,30020,CDM,450,RC,30020,HCPCS,outpatient,,,$199.00 ,$69.65 ,,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$149.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges,$62.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.81 ,$189.05 ,
30300-Intranasal,30300,CDM,450,RC,30300,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.15 ,$161.50 ,
30310 -  Intranasal w/Anesthesia,30310,CDM,450,RC,30310,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
30901-Anterior Simple,30901,CDM,450,RC,30901,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
30903-Anterior Complex,30903,CDM,450,RC,30903,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.15 ,$161.50 ,
30905-Posterior Initial,30905,CDM,450,RC,30905,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
30906-Posterior Subsequent,30906,CDM,450,RC,30906,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
31238 - Endoscopy w/control Nasal,31238,CDM,450,RC,31238,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
31500-Endotracheal Intubation,31500,CDM,450,RC,31500,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
31502-Tracheotomy Tube Change,31502,CDM,450,RC,31502,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31505-Indirect Laryngoscopy,31505,CDM,450,RC,31505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31525-Direct Laryngoscopy Diagnostic,31525,CDM,450,RC,31525,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
31530 - Laryngoscopy w/foreign removal,31530,CDM,450,RC,31530,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
31575-Laryngoscopy Flexible Diagnostic,31575,CDM,450,RC,31575,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31603-Tracheostomy Transtracheal,31603,CDM,450,RC,31603,HCPCS,outpatient,,,$180.00 ,$63.00 ,,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$135.00 ,75,,,percent of total billed charges,75% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges,$56.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.10 ,$171.00 ,
"31605-Tracheostomy,emergency procedure",31505,CDM,450,RC,31605,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
31899 - Proc trachea/bronchi,31899,CDM,450,RC,31899,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
32550-Insertion Tunneled Pleural Cath,32550,CDM,450,RC,32550,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
32551-Insertion Chest Tube,32551,CDM,450,RC,32551,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
32554-Thoracentesis w/o Imaging Guidance,32554,CDM,450,RC,32554,HCPCS,outpatient,,,$190.00 ,$66.50 ,,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.50 ,75,,,percent of total billed charges,75% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$171.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$142.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.05 ,$180.50 ,
32555-Thoracentesis w/ Imaging Guidance,32555,CDM,450,RC,32555,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
"32556 - Drainage, percutaneous w/o guidance",32556,CDM,450,RC,32556,HCPCS,outpatient,,,$170.00 ,$59.50 ,,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.50 ,75,,,percent of total billed charges,75% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges,$53.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.15 ,$161.50 ,
32560 - Instillation chest tube/cath,32560,CDM,450,RC,32560,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
32999 - Proc lungs/pleura,32999,CDM,450,RC,32999,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36000-Introduction Needle/Intracath Vein,36000,CDM,450,RC,36000,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36410-Venipuncture Requires Greater Than/Equal to 3 Year MD,36410,CDM,450,RC,36410,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36420 - Venipuncture; < 1 yr,36420,CDM,450,RC,36420,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36425 - Venipuncture cutdown; > 1 yr,34625,CDM,450,RC,,HCPCS,outpatient,,,"$1,495.41 ",$523.39 ,,$801.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$801.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges,$472.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$523.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,046.79 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,046.79 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,151.47 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$468.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$468.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$463.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,345.87 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$300.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,420.64 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,196.33 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,390.73 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,121.56 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,271.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$291.60 ,"$1,420.64 ",
36556-Central Line Greater Than/Equal to 5 Years,36556,CDM,450,RC,36556,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
36557-Insert Central Venous Cath<5yrs,36557,CDM,450,RC,36557,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
36558 - Insert Central Venous cath w/o port,36558,CDM,450,RC,36558,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36565 - Insertion of Tunneled Centrally CVA Device,36565,CDM,450,RC,36565,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
36569-PICC Line Insertion Greater Than/Equal to 5 Years,36569,CDM,450,RC,36569,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36573 - PICC Line Insertion w/o Port/Pump,36573,CDM,450,RC,36573,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36578 - Replacement CVA device,36578,CDM,450,RC,36575,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
36589 - Removal Tunneled Central Venous Cath,36589,CDM,450,RC,36589,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
36590-Removal Tunneled CVA Device,36590,CDM,450,RC,36590,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
36591-Collect Blood Port/Access Device,36591,CDM,450,RC,36591,HCPCS,outpatient,,,$15.00 ,$5.25 ,,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,75,,,percent of total billed charges,75% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.93 ,$14.25 ,
36592- Blood Central/Peripheral Cath,36592,CDM,450,RC,36592,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
36600-Arterial Puncture,36600,CDM,450,RC,36600,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
36620-Arterial Catheterization,36620,CDM,450,RC,36620,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
36625 - Arterial Catheterization,36625,CDM,450,RC,36625,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
36680-Place Needle Intraosseous Infusion,36680,CDM,450,RC,36680,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
37195-Thrombolysis Cerebral,37195,CDM,450,RC,37195,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
"37609 - Ligation/Biopsy, temporal artery",37609,CDM,450,RC,37609,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
37799 - Proc vascular surg,37799,CDM,450,RC,37799,HCPCS,outpatient,,,$230.00 ,$80.50 ,,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$172.50 ,75,,,percent of total billed charges,75% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges,$72.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.85 ,$218.50 ,
38220 - Aspiration Bone Marrow,38220,CDM,450,RC,38220,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
38221-Bone Marrow Biopsy,38221,CDM,450,RC,38221,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
38505 - Biopsy of lymph nodes by needle,38505,CDM,450,RC,38505,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
40650-Lip Full Thickness Vermilion Only,40650,CDM,450,RC,40650,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
40800-I&D Cyst Mouth Simple,40800,CDM,450,RC,40800,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
40801-I&D Cyst Mouth Complicated,40801,CDM,450,RC,40801,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
40804 - Vestibule of Mouth; simple,11721,CDM,450,RC,40804,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
40830 - Mouth Laceration; 2.5 cm or Less,40830,CDM,450,RC,40830,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
"40831-Closure of laceration, vestibule of mouth",40831,CDM,450,RC,40831,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41016 - I&D Abscess Floor of Mouth; Submental,41016,CDM,450,RC,41016,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
41108 - Biopsy of Floor of Mouth,41108,CDM,450,RC,41108,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
41250-Mouth Floor/Tongue Ant 2/3 Less Than/Equal to 2.5cm,41250,CDM,450,RC,41250,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41251-MF/T Posterior 1/3 Less Than/Equal to 2.5 cm,41251,CDM,450,RC,41251,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
41599 - Unlisted Procedure Tongue/Floor of Mouth,41599,CDM,450,RC,41599,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
41800-Drainage Abscess/Cyst Dentoalveolar,41800,CDM,450,RC,41800,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
41899 - Dentoalveolar structures,41899,CDM,450,RC,41899,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
42000-Drainage Abscess Palate/Uvula,42000,CDM,450,RC,42000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
42700-I&D Peritonsillar Abscess,42700,CDM,450,RC,42700,HCPCS,outpatient,,,$168.00 ,$58.80 ,,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$126.00 ,75,,,percent of total billed charges,75% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges,$53.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$151.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.76 ,$159.60 ,
42809-Pharynx,42809,CDM,450,RC,42809,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
42960 - Simple oropharyngeal hemorrage,42960,CDM,450,RC,42960,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
42999 - Proc pharynx/adenoids/tonsils,42999,CDM,450,RC,42999,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
43246 - Esophagogastroduodenoscopy,43246,CDM,450,RC,43246,HCPCS,outpatient,,,$700.00 ,$245.00 ,,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$245.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$539.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$217.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$630.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$665.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.50 ,$665.00 ,
43247-EGD w/ Removal Foreign Body,43247,CDM,450,RC,43247,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
43249 - Esophagogastroduodenoscopy,43249,CDM,450,RC,43249,HCPCS,outpatient,,,$700.00 ,$245.00 ,,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$245.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$539.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$217.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$630.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$665.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.50 ,$665.00 ,
43752-Insertion NG tube,43752,CDM,450,RC,43752,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43753-Gastric Intubation w/ Lavage,43753,CDM,450,RC,43753,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43754 -Gastric Intubation and Aspiration,43754,CDM,450,RC,43754,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43762-Replacement of gastrostomy tube,43762,CDM,450,RC,43762,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
43763-Replacement of gastrostomy tube,43763,CDM,450,RC,43763,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
45900-Reduce procidentia w/anesthesia,45900,CDM,450,RC,45900,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
45910-Manipulation Procedures on the Rectum,45910,CDM,450,RC,45910,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
45915-Fecal Impaction w/ Anesthesia,45915,CDM,450,RC,45915,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
46040-I&D Ischiorectal/Perirectal Abscess,46040,CDM,450,RC,46040,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46050-I&D Perianal Abscess Superficial,46050,CDM,450,RC,46050,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46083-Incision Hemorrhoid Thrombosed External,46083,CDM,450,RC,46083,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
46320-Excision External Thrombosed Hemorrhoid,46320,CDM,450,RC,46320,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
46600 - Anoscopy; Diagnostic,46600,CDM,450,RC,46600,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
49082-Abdominal Paracentesis w/o Imaging Guide,49082,CDM,450,RC,49082,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
49083-Abdominal Paracentesis w/ Imaging Guide,49083,CDM,450,RC,49083,HCPCS,outpatient,,,"$1,500.00 ",$525.00 ,,$804.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$804.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges,$474.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$525.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,050.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,050.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,155.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$465.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,350.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$301.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,425.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$301.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,275.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$292.50 ,"$1,425.00 ",
49084 - Peritoneal Lavage,49084,CDM,450,RC,49084,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
49440 - Insertion Gastrostomy Tube w/contrast,49440,CDM,450,RC,49440,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
49450 - Replace gastro/ceco tube,49450,CDM,450,RC,49450,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
49451 - Jejunostomy tube replacement,49451,CDM,450,RC,49451,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
51040 - Cystostomy,51040,CDM,450,RC,51040,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
51102 - Aspiration bladder w/supra cath,51102,CDM,450,RC,51102,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51700-Bladder Irrigation Simple Lavage/Instill,51700,CDM,450,RC,51700,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51701-Insert Bladder Cath Non-Dwelling,51701,CDM,450,RC,51701,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
51702-Insertion Indwelling Catheter,51702,CDM,450,RC,51702,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
51703-Insert Indwelling Cath Complicated,51703,CDM,450,RC,51703,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
51705-Change Cystostomy Tube Simple,51705,CDM,450,RC,51705,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
51798 - Post-Voiding Residual Urine w/US,51798,CDM,450,RC,51798,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
52005 - Cystourethroscopy w/uret cath,52005,CDM,450,RC,52005,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
53620-Dilation Urethral Stricture Filiform Male,53620,CDM,450,RC,53620,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
54220-Irrigation Corpora Cavernosa,54220,CDM,450,RC,54220,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
54230-Injection Procedure Corpora Cavern,54230,CDM,450,RC,54230,HCPCS,outpatient,,,$50.00 ,$17.50 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,$47.50 ,
54235-Injection Corpora Cavernosa,54235,CDM,450,RC,54235,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
54700-I&D Epididymis/Testis/Scrotal Space,54700,CDM,450,RC,54700,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
55100-Drainage Scrotal Wall Abscess,55100,CDM,450,RC,55100,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
55120-Scrotum,55120,CDM,450,RC,55120,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
55899 - Proc male genital,55899,CDM,450,RC,55899,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
56405-I&D Vulva/Perineal Abscess,56405,CDM,450,RC,56405,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
56420-I&D Bartholin Abscess,56420,CDM,450,RC,56420,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
56820 - Colposcopy of Vulva,56820,CDM,450,RC,56820,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
57200 - Colporrhaphy,57200,CDM,450,RC,57200,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
58301-Intrauterine Device,58301,CDM,450,RC,58301,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
59409-Vaginal Delivery Only,59409,CDM,450,RC,59409,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
59414 - Delivery of Placenta,59414,CDM,450,RC,59414,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
62270-Lumbar Puncture Diagnostic,62270,CDM,450,RC,62270,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
62273-Inject Epidural Blood/Clot Patch,62273,CDM,450,RC,62273,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
64400-Injection Nerve Block Trigeminal,64400,CDM,450,RC,64400,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.79 ,$115.90 ,
64405-Inject Nerve Block Great Occipital,64405,CDM,450,RC,64405,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.79 ,$115.90 ,
64415 - Inj; Brachial Plexus w/Imaging,64415,CDM,450,RC,64415,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
64450-Injection Nerve Block Peripheral,64450,CDM,450,RC,64450,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
64505 - Inj; Sphenopalatine Ganglion,64505,CDM,450,RC,64505,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"64999-Unlisted Procedure, Nervous System",64999,CDM,450,RC,64999,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
65205-Conjuctival Superficial,65205,CDM,450,RC,65205,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
65210 - External Eye,65210,CDM,450,RC,65210,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
65220-Corneal w/o Slit Lamp,65220,CDM,450,RC,65220,HCPCS,outpatient,,,$160.00 ,$56.00 ,,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$120.00 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$152.00 ,
65222-Corneal w/ Slit Lamp,65222,CDM,450,RC,65222,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
65235-Anterior Chamber of Eye/Lens,65235,CDM,450,RC,65235,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
65435 - Removal of Corneal Epithelium,65435,CDM,450,RC,65435,HCPCS,outpatient,,,$188.00 ,$65.80 ,,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$141.00 ,75,,,percent of total billed charges,75% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges,$59.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.66 ,$178.60 ,
66999 - Proc anterior segment of eye,66999,CDM,450,RC,66999,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
67700-Drain Abscess Blepharotomy/Eyelid,67700,CDM,450,RC,67700,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
67800-Excision of Chalazion; Single,67800,CDM,450,RC,67800,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
67938-Eyelid Embedded Foreign Body,67938,CDM,450,RC,67938,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
69000-Drainage External Ear Abscess/Hematoma,69000,CDM,450,RC,69000,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69020-Drainage External Auditory Canal Abscess,69020,CDM,450,RC,69020,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69200-External Auditory Canal,69200,CDM,450,RC,69200,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
69205 - External Auditory Canal; w/Anesthesia,69205,CDM,450,RC,69205,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
69209-Cerumen Irrigation/Lavage,69209,CDM,450,RC,69209,HCPCS,outpatient,,,$165.00 ,$57.75 ,,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.75 ,75,,,percent of total billed charges,75% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges,$52.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,$156.75 ,
69210-Cerumen w/ Instrumentation,69210,CDM,450,RC,69210,HCPCS,outpatient,,,$140.00 ,$49.00 ,,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$105.00 ,75,,,percent of total billed charges,75% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges,$44.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.30 ,$133.00 ,
84112-Eval Cervicovaginal fluid,84112,CDM,450,RC,84112,HCPCS,outpatient,,,$115.00 ,$40.25 ,,$61.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$61.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.25 ,75,,,percent of total billed charges,75% of total billed charges,$86.25 ,75,,,percent of total billed charges,75% of total billed charges,$86.25 ,75,,,percent of total billed charges,75% of total billed charges,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$100.07 ,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,$92.00 ,80,,,percent of total billed charges,80% of total billed charges,$36.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$76.14 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$92.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.96 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$99.09 ,101,,,fee schedule,101% CMS Medicare OPPS fee schedule rate for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.51 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$98.11 ,100,,,fee schedule,100% CMS Medicare OPPS fee schedule rate for outpatient setting,$103.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$94.26 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$109.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.96 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.69 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$97.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.96 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$36.36 ,$109.25 ,
90460 - Immunization Admin through 18 yrs,90460,CDM,450,RC,90460,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
90471-Vaccine Administration,90471,CDM,771,RC,90471,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
90472-Vaccine Administration Each Addl,90472,CDM,450,RC,90472,HCPCS,outpatient,,,$35.00 ,$12.25 ,,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.25 ,75,,,percent of total billed charges,75% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges,$11.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.83 ,$33.25 ,
92950-Cardiopulmonary Resuscitation,92950,CDM,450,RC,92950,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
92953 - Temporary Transcutaneous Pacing,92953,CDM,450,RC,92953,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
92960 - Cardioversion; Elective,92960,CDM,450,RC,92960,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
93005-ED EKG,93005,CDM,450,RC,93005,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96360-59 IV Hydration Initial Addl Site w/ Modification,96360,CDM,450,RC,96360,HCPCS,outpatient,,,$322.36 ,$112.83 ,,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$290.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.86 ,$306.24 ,
96360-IV Hydration Initial 31 min - 1 hr,96360,CDM,450,RC,96360,HCPCS,outpatient,,,$322.36 ,$112.83 ,,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$241.77 ,75,,,percent of total billed charges,75% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges,$101.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$290.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.86 ,$306.24 ,
96361-IV Hydration Each Addl Hour Greater Than 30 mins,96361,CDM,450,RC,96361,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96365-59 Infusion Initial Addl Site w/ Modification,96365,CDM,450,RC,96365,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96365-Infusion Drug Initial up to 1 hr Greater Than 15 mins,96365,CDM,450,RC,96365,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96366-Infuse Drug Each Addl Hour Greater Than 30 mins,96366,CDM,450,RC,96366,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96367-Infusion Sequential 1 hr Greater Than 15 mins,96367,CDM,450,RC,96367,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96368-Infusion Concurrent Greater Than 15 mins,96368,CDM,450,RC,96368,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96372-59 SQ/IM Injection w/ Modification,96372,CDM,450,RC,96372,HCPCS,outpatient,,,$138.65 ,$48.53 ,,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.04 ,$131.72 ,
96372-Injection/SQ/IM,96372,CDM,450,RC,96372,HCPCS,outpatient,,,$138.65 ,$48.53 ,,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$103.99 ,75,,,percent of total billed charges,75% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges,$43.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.04 ,$131.72 ,
96374-59 IV Push Initial Drug Addl Site w/ Modification,96374,CDM,450,RC,96374,HCPCS,outpatient,,,$153.15 ,$53.60 ,,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$47.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$137.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.86 ,$145.49 ,
96374-IV Push Initial Drug,96374,CDM,450,RC,96374,HCPCS,outpatient,,,$153.15 ,$53.60 ,,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$114.86 ,75,,,percent of total billed charges,75% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges,$48.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$53.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$117.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$47.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$137.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$114.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.86 ,$145.49 ,
96375-IV Push Each Additional New Drug,96375,CDM,450,RC,96375,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96376-IV Push Addl Same Drug Greater Than 30 mins,96376,CDM,450,RC,96376,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
96523 - Irrigation IVA device,96523,CDM,450,RC,96523,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
97597-Devitalized Tissue Less Than/Equal to 1st 20 sq cm,97597,CDM,450,RC,97597,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99151-Same MD First 15 mins Less Than 5 yrs,99151,CDM,450,RC,99151,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99152-Same MD First 15 mins Greater Than/Equal to 5 yrs,99152,CDM,450,RC,99152,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99153-Same MD Each Additional 15 mins,99153,CDM,450,RC,99153,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99155-Different MD First 15 mins Less Than 5 yrs,99155,CDM,450,RC,99155,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99156-Different MD First 15 mins Greater Than/Equal to 5 yrs,99156,CDM,450,RC,99156,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
99157-Different MD Each Addl 15 mins,99157,CDM,450,RC,99157,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
AMB Only Inj Med Admin Charge,1648367,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Admin Immunization Charge,20325,CDM,771,RC,90715,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$38.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.52 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.36 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$37.82 ,$115.90 ,
Admin Immunization Charge,20325,CDM,771,RC,90715,HCPCS,outpatient,,,$122.00 ,$42.70 ,,$38.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$38.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.50 ,75,,,percent of total billed charges,75% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges,$38.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.52 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.21 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$37.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$109.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$115.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.36 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$91.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$103.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.13 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$37.82 ,$115.90 ,
Arterial Puncture,12007,CDM,300,RC,36600,HCPCS,outpatient,,,$111.95 ,$39.18 ,,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.83 ,$106.35 ,
BiPAP/CPAP Machine Model -> Patient's Home Unit,20326,CDM,410,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
G0260-Injection Arthrogram Sacroiliac w/ Anesthesia,G0260,CDM,450,RC,,HCPCS,outpatient,,,$130.00 ,$45.50 ,,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$97.50 ,75,,,percent of total billed charges,75% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges,$41.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.35 ,$123.50 ,
G0390-811 Preactivation Trauma Response,G0390,CDM,450,RC,,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
G0390-911 Preactivation Trauma Response,G0390,CDM,450,RC,,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
Misc Nursing Task,8033105,CDM,637,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Misc Nursing Task,8124613,CDM,637,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Q3014-Telehealth,Q3014,CDM,450,RC,,HCPCS,outpatient,,,$117.00 ,$40.95 ,,$62.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.60 ,80,,,percent of total billed charges,80% of total billed charges,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$105.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.82 ,$111.15 ,
ROOM/BED: Behavioral Health,1010,CDM,114,RC,,HCPCS,inpatient,,,"$1,029.60 ",$360.36 ,,$619.82 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$619.82 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$772.20 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$772.20 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$772.20 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,$823.68 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$823.68 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$720.72 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$720.72 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$792.79 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$926.64 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$978.12 ,95,,,percent of total billed charges,95% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$823.68 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$926.64 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$875.16 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$619.82 ,"$2,391.02 ",
ROOM/BED: Direct Admit,30199,CDM,762,RC,,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
ROOM/BED: Hospice,2009,CDM,115,RC,,HCPCS,inpatient,,,$762.00 ,$266.70 ,,$458.72 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$458.72 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,$609.60 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$609.60 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$533.40 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$533.40 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$586.74 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$685.80 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$723.90 ,95,,,percent of total billed charges,95% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$609.60 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$685.80 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$571.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$647.70 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$458.72 ,"$2,391.02 ",
ROOM/BED: ICU,1006,CDM,202,RC,,HCPCS,inpatient,,,$858.00 ,$300.30 ,,$516.52 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$516.52 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,$686.40 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$686.40 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$600.60 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$600.60 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$660.66 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$772.20 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$815.10 ,95,,,percent of total billed charges,95% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$686.40 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$772.20 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$643.50 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$729.30 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$516.52 ,"$2,391.02 ",
ROOM/BED: Inpatient,1001,CDM,111,RC,,HCPCS,inpatient,,,$480.48 ,$168.17 ,,$289.25 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$289.25 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$336.34 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$369.97 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$456.46 ,95,,,percent of total billed charges,95% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$384.38 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$432.43 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$360.36 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$408.41 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$289.25 ,"$2,391.02 ",
ROOM/BED: Observation,1007,CDM,762,RC,,HCPCS,outpatient,,,$22.00 ,$7.70 ,,$11.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.60 ,80,,,percent of total billed charges,80% of total billed charges,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.29 ,$20.90 ,
ROOM/BED: Respite,29001,CDM,167,RC,,HCPCS,inpatient,,,$160.88 ,$56.31 ,,$96.85 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$96.85 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,$128.70 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$128.70 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$112.62 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$112.62 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$123.88 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,$144.79 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$152.84 ,95,,,percent of total billed charges,95% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$128.70 ,80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$144.79 ,90,,,percent of total billed charges,90% of total billed charges for inpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$120.66 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,$136.75 ,85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$96.85 ,"$2,391.02 ",
ROOM/BED: SNF,1009,CDM,121,RC,,HCPCS,inpatient,,,"$1,283.57 ",$449.25 ,,$772.71 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$772.71 ,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient seeting,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$1,026.86 ",80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,"$1,026.86 ",80,,,percent of total billed charges,80% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,$898.50 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$898.50 ,70,,,percent of total billed charges,70% of total billed charges for inpatient setting,$988.35 ,77,,,percent of total billed charges,77% of total billed charges for inpatient setting,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,"$1,155.21 ",90,,,percent of total billed charges,90% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,"$1,219.39 ",95,,,percent of total billed charges,95% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,026.86 ",80,,,percent of total billed charges,80% of total billed charges for inpatient setting,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,"$1,155.21 ",90,,,percent of total billed charges,90% of total billed charges for inpatient setting,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,$962.68 ,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,"$1,091.03 ",85,,,percent of total billed charges,85% of total billed charges for inpatient setting,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,$772.71 ,"$2,391.02 ",
00002-4182-30 - BARICITINIB 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7510-01 - INSULIN LISPRO 100 UNITS/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7510-17 - INSULIN LISPRO 100 UNITS/1 ML VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7511-01 - INSULIN HumaLOG/HumuLIN  N 75/25 100 UNITS/1 ML VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7533-01 - INSULIN LISPRO 100 UNIST/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7589-01 - BEBTELOVIMAB *IVP* 175 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-7597-01 - OLANZAPINE 10 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-8215-01 - insulin regular human recombinant 100 units/mL sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-8215-17 - insulin regular human recombinant 100 units/mL Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-8315-01 - insulin isophane (NPH) human recombinant 100 units/mL Sus,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00002-8715-01 - INSULIN SIOPHANE/INSULIN REGULAR HUMAN RECOMBINANT 70/30 UNITS/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00003-0893-31 - APIXABAN 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00003-0894-21 - APIXABAN 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00003-0894-31 - APIXABAN 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00003-2560-16 - AZTREONAM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00003-2570-16 - AZTREONAM 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00005-2000-02 - PNEUMOCCOCCAL 20-VALENT CONJUGATE VACCINE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-0032-20 - IVERMECTIN 3 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-0112-28 - sitaGLIPtin 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-0112-31 - sitaGLIPtin 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-0227-61 - RALTEGRAVIR 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-4837-03 - VAC - PNEUMOVAX-23 INJ 0.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-5423-12 - SUGAMMADEX 200 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00006-5424-02 - BLACK WIDOW ANTIVENIN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0005-01 - Hydrocortisone Sod Succ 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0011-03 - Hydrocortisone Sod Succ 100 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0011-04 - HYDROCORTISONE SOD SUCCINATE 100 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0013-06 - Hydrocortisone Sod Succ 250 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0018-20 - methylPREDNISolone 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0039-28 - methylPREDNISolone sod succ 40 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0039-32 - methylPREDNISolone 40 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0047-22 - methylPREDNISolone SOD SUCC 125 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0047-26 - methylPREDNISolone 125 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0086-01 - TESTOSTERONE CYPIONATE 200 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0271-01 - ESTRADIOL CYPIONATE 5 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0417-02 - TESTOSTERONE CYPIONATE 200 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-0555-01 - LINCOMYCIN 300 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-4992-02 - LINEZOLID PREMIX 600 MG/300 ML,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-5400-01 - NICOTINE 10 MG INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00009-7376-11 - MEDROXYPROGESTERONE 150 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00019-4816-04 - GASTROVIEW SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00023-0312-04 - ARTIFICIAL TEARS OPTH OINTMENT 3.5 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00023-3205-03 - BIMATOPROST 0.01% OPTH SOLUTION 2.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00023-9321-05 - BRIMONIDINE 0.1% OPTH DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00024-2792-10 - SOD FERRIC GLUCONATE IN SUCROSE 62.5 MG/5 ML Inj [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00032-1212-01 - PANCRELIPASE DR 12,000 UNITS CAPSULE [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00032-1224-01 - PANCRELIPASE 24,000 UNITS CAP [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00037-6823-15 - PRAMOXINE 1% HEMORRHOIDAL FOAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00046-1102-81 - CONJUGATED ESTROGENS 0.625 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00049-0014-83 - AMPICILLIN/ SULBACTAM 3 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00049-0520-22 - PENICILLIN G POTASSIUM 5 MILLION UNITS INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00049-0520-83 - PENICILLIN G POT 5 million unit inj [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00049-0530-28 - PENICILLIN G POT 20 MU INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0017-20 - predniSONE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0018-20 - predniSONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0235-24 - MORPHINE IMMEDIATE RELEASE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0326-56 - FLUTICASONE-SALMETEROL 100-50 MCG INHALATION POWDER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0327-56 - FLUTICASONE/SALMETEROL DISK INHALER 250-50 MCG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0517-44 - MORPHINE 20 MG/1 ML ORAL SOLUTION (1 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-0742-87 - ALBUTEROL HFA 90 MCG INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3194-46 - DIPHENOXYLATE/ATROPINE 2.5/0.025 MG/5 ML OS[JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3270-99 - FLUTICASONE PROPIONATE 50 MCG/SPRAY NASAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3294-46 - FUROSEMIDE 50 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3294-50 - FUROSEMIDE 50 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3500-49 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-3545-63 - MEPERIDINE HCL 50 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-4184-25 - dexAMETHasone 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8175-25 - dexAMETHasone 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8297-25 - FUROSEMIDE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8299-25 - FUROSEMIDE 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8527-25 - lithium 300 mg Cap UD [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8724-25 - predniSONE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00054-8739-25 - predniSONE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00065-0303-55 - ATROPINE 1% OPHTH SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00065-0647-25 - TOBRAMYC/DEXAMETH OPTH SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00065-0741-14 - TETRACAINE 0.5% OPTH SOLUTION 4 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00065-0817-01 - ATROPINE 1% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00067-8152-03 - DICLOFENAC SODIUM 1% GEL 100 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00069-0248-10 - PROPOFOL 1000 MG/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00078-0876-01 - TOBRAMYCIN/DEXAMETH OPTH OINT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00087-0740-02 - FERROUS SULFATE 15 MG/1 ML DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00088-2220-33 - INSULIN GLARGINE 100 UNITS/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00088-5021-01 - INS GLARGINE - 100 UNITS/ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-0311-01 - LOPERAMIDE 2 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-0314-01 - KETOROLAC 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-0318-01 - diltiaZEM 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-1712-01 - WARFARIN 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-2027-23 - AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-2210-01 - SUCRALFATE 1 GM TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-3107-01 - AMOXICILLIN 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-3174-31 - ALBUTEROL HFA 90 MCG PER ACTUATION INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-3212-01 - ClonaZEPAM 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-3422-01 - CYCLOBENZAPRINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-3426-01 - LORazepam 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-4125-74 - penicillin V potassium 125 mg/5 mL Pow,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-4127-74 - PENICILLIN V POT 250 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-4147-56 - RT LEVALBUTEROL 1.25 MG/0.5 ML INHALATION SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-4177-73 - CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-7163-98 - TOLTERODINE TARTRATE ER 2 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-7701-98 - LEVOCETIRIZINE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-8035-01 - glyBURIDE 3 MG TAB (MICRONIZED) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-8180-64 - OSELTAMIVIR SUSP 6 MG/ML BOTTLE 60 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00093-8343-01 - glyBURIDE 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00115-1645-01 - NITROFURANTOIN 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00115-1700-01 - HYDROCORTISONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00115-7033-01 - FLUDROCORTISONE 0.1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0431-30 - MAGNESIUM HYDROXIDE 2400 MG/30 ML,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0504-05 - ACETAMINOPHEN/CODEINE 120/12 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0747-10 - SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0759-08 - prednisoLONE 15 MG/5 ML ORAL SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0854-16 - SULFAMETHOXAZOLE/TRIMETHOPRIM 400/80 MG PER 10 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0867-20 - VANCOMYCIN 125 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00121-0868-00 - NYSTATIN 500,000 UNITS/5 ML ORAL SUSPENSION [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00121-0868-50 - NYSTATIN SUSP 500,000 UNIT/5 ML [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0890-20 - VANCOMYCIN 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0903-40 - LIDOCAINE VISCOUS 2% OS 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0914-00 - IBUPROFEN 100 MG/5 ML CHILDRENS ORALSUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0928-16 - PROMETHAZINE/CODEINE 6.25/10 MG PER 5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0942-16 - PHENobarbital 20 MG/5 ML ELIXIR [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0945-40 - MEGESTROL 400 MG/10 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-0974-40 - SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1154-40 - LACTULOSE 20 GM/30 ML SOLUTION,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1276-00 - guaiFENesin/DEXTROMETHORPHAN 200/20 MG/10 ML ORAL SOLLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1550-00 - GUAIFENESIN/CODEINE 200/20 MG PER 10 ML ORAL SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1680-16 - POTASSIUM CHL 10% 20 MEQ/15 ML ORAL SOLUTION (KAON) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1730-00 - diphenhydrAMINE 25 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1744-05 - guaiFENesin 100 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1775-05 - CODEINE-guaiFENesin 10-100 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1781-05 - ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-1870-00 - DOCUSATE SODIUM 100 MG/10 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-4675-05 - VALPROIC ACID 250 MG/5 ML SYRUP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00121-4799-05 - levETIRAcetam 500 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00132-0079-24 - GLYCERIN ADULT 2 GM SUPPOSITORY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00132-0081-12 - GLYCERIN PEDIATRIC 1 GM SUPPOSITORY,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00132-0202-20 - FLEET ENEMA SALINE PEDIATRIC [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-1241-01 - DIGOXIN 0.25 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-1500-01 - PHENobarbital 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9233-05 - BENZTROPINE 2 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9234-10 - VECURONIUM 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9262-25 - ceFAZolin 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9284-10 - PANTOPRAZOLE 40 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9316-24 - LevoFLOXACIN 500 MG/100 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9317-24 - LevoFLOXACIN 750 MG/150 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9365-10 - LABETALOL PREMIX 300 MG/300 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9375-10 - TERBUTALINE 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9503-01 - acetaZOLAMIDE 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9506-10 - ETOMIDATE 20 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9508-10 - KETAMINE 500 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9595-25 - LIDOCAINE 1% (MPF) 50 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9633-10 - niCARdipine PREMIX 40 MG IN 0.9% SODIUM CHL 200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9684-10 - FLUMAZENIL 0.5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9689-10 - NICARDIPINE 25 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9720-01 - levoFLOXacin PREMIX 750 MG/150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9720-24 - levoFLOXacin PREMIX 750 MG/150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9721-01 - levoFLOXacin PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9721-24 - levoFLOXacin PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9722-01 - levoFLOXacin PREMIX 250 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9722-24 - LevoFLOXacin PREMIX 250 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9746-10 - TERBUTALINE 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9784-10 - FLUMAZENIL 0.5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9872-10 - PROPRANOLOL 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9875-25 - AMIODARONE 150 MG/3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9888-01 - AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION (100 ML),,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00143-9889-15 - AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION 150 ML,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00168-0007-15 - NYSTATIN 100,000 UNITS/GM OINTMENT 15 GM",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00168-0080-31 - HYDROCORTISONE 2.5 % CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00168-0357-30 - lidocaine-prilocaine topical 2.5%-2.5% Cre,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00168-0357-55 - LIDOCAINE/PRILOCAINE 2.5%/2.5% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00169-1833-11 - INSULIN REGULAR HUMAN RECOMBINANT 100 UNITS/1 ML VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00169-1834-11 - INSULIN NPH HUMAN RECOMBINANT 100 UNITS/1 ML VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00169-1837-11 - INSULIN NPH/REG 70/30 100 UNITS/1 ML VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00169-3687-12 - INS DETEMIR - 100 UNITS/ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00172-3925-60 - diAZEpam 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00172-3926-60 - diAZEpam 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00173-0682-24 - ALBUTEROL 90 MCG PER ACTUATION INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00173-0695-04 - FLUTICASONE/SALMETEROL DISK INHALER 100-50 MCG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00173-0697-04 - FLUTICASONE/SALMETEROL DISK INHALER 500-50 MCG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00185-0674-01 - hydrOXYzine PAMOATE 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00185-5050-01 - metOLazone 2.5 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00186-0370-28 - BUDESONIDE-FORMOTEROL 160-4.5 MCG INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00186-0916-12 - BUDESONIDE 180 MCG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00223-1721-01 - SODIUM BICARBONATE 650 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00225-0382-80 - SODIUM CHLORIDE NASAL 0.65% DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00225-0800-47 - PHENYLEPHRINE 0.25% NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00225-0810-47 - PHENYLEPHRINE 1% NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00228-2029-10 - ALPRAZolam 0.5 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00228-2069-10 - OXAZEPAM 15 MG CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00228-2538-10 - CARBIDOPA/LEVODOPA 10/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00228-2571-11 - INDAPAMIDE 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00228-2620-11 - ISOSORBIDE MONO 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-0012-01 - SOTALOL 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-0147-01 - AMIODARONE HCL 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-0213-11 - MIDODRINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-5316-01 - POTASSIUM CHL ER 10 MEQ TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-5317-89 - POTASSIUM CHL ER 10 MEQ TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-5319-01 - POTASSIUM CHL ER 20 MEQ TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00245-5326-30 - POTASSIUM BICARBONATE 25 MEQ TAB (EFFERVESCENT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00254-1011-96 - SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-1800-36 - IV NS 25 ML [JDHS],,CDM,258,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-1965-10 - HETASTARCH 6% PREMIX 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-3103-11 - ceFAZolin 1 GM PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-3105-11 - ceFAZolin 2 GM PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-4100-90 - ACETAMINOPHEN PREMIX 1000 MG/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-4204-52 - MAGNESIUM (PREMIX) 2 GM/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-4206-54 - MAGNESIUM SULFATE PREMIX 4 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-7510-20 - IV D5W 250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-7800-10 - IV NS 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-7802-00 - IV 1/2 NS 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00264-9587-20 - HEPARIN 25,000 UNITS/250 ML PREMIX [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00264-9594-10 - LIDOCAINE (PREMIX) 2 GM/500 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00270-0445-35 - DIATRIZOATE 66/10% 30 ML SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00270-5164-15 - DIMEGLUMINE 529 MG/1 ML INJ (20 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00281-0326-08 - NITROGLYCERIN 2% OINT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00283-0610-11 - BENZOCAINE 20% ORAL ANESTHETIC SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00310-0095-30 - ROFLUMILAST 500 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00310-1110-39 - SODIUM ZIRCONIUM CYCLOSILICATE 10 GM PKT ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00310-7370-20 - BUDESONIDE/FORMOTEROL 160/4.5 MCG INH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0013-04 - STERILE WATER FOR INJ 1000 ML [JDHS],,CDM,258,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-02 - IV DEXTROSE 5% 250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-03 - IV D5W 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-04 - IV D5W 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-10 - IV D5W 25 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-18 - IV DEXTROSE 5% 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-31 - IV D5W 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0017-38 - IV DEXTROSE 5% 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0023-03 - IV D10W 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0043-04 - IV SODIUM CHLORIDE 0.45% 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-02 - IV NS 250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-03 - IV SODIUM CHLORIDE 0.9% 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-04 - IV SODIUM CHLORIDE 0.9% 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-11 - IV SODIUM CHLORIDE 0.9% 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-18 - IV SODIUM CHLORIDE 0.9% 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-31 - IV SODIUM CHLORIDE 0.9% 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0049-38 - IV SODIUM CHLORIDE 0.9% 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0054-03 - IV 3% HYPERTONIC SALINE 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0072-25 - KETOROLAC 30 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0085-04 - IV Dextrose 5% with 0.45% NaCl 1000 ML [JDHS],,CDM,258,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0089-04 - IV D5 NS 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0117-04 - IV LACTATED RINGER'S 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0126-12 - INSULIN REGULAR HUMAN RECOMBINANT PREMIX 100 UNITS/100 ML 0.9% SOD CHL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0357-03 - MANNITOL 20% PREMIX 100 GM/500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0409-03 - LIDOCAINE PREMIX 2 GM in 5% DEXTROSE 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0551-11 - IV D5W MINIBAG PLUS 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0553-18 - IV NS MINIBAG PLUS 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0669-04 - IV D5 1/2 NS W/10 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0671-04 - IV D5 1/2 NS W/20 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0675-04 - IV D5 1/2 NS W/40 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0691-04 - IV SODIUM CHLORIDE 0.9% with KCL 20 MEQ 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0695-04 - IV NS W/40 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0703-48 - POTASSIUM CHLORIDE PREMIX 40 MEQ/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0704-34 - IV 1/2 NS W/20 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0705-48 - POTASSIUM CHLORIDE PREMIX 20 MEQ/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0709-48 - POTASSIUM CHL (PREMIX) 10 MEQ/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0803-04 - IV D5 NS W/20 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-0807-04 - IV DEXTROSE 5% and SODIUM CHLORIDE 0.9% with KCL 40 MEQ 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1007-02 - DOPamine PREMIX 400 MG in 5% DEXTROSE 250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1047-02 - NITROGLYCERIN/ DEX 5% 25 MG/250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1055-48 - metroNIDAZOLE PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1101-04 - CLINIMIX 5/20% 2000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1134-03 - CLINIMIX 4.25%/DEXTROSE 10% - 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1138-03 - AMINO ACIDS 5%/ DEXTROSE 20% - 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1708-40 - MAGNESIUM SULFATE 2 GM/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1709-40 - MAGNESIUM SULFATE PREMIX 1 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-1715-40 - MAGNESIUM SULFATE PREMIX 4 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-3410-24 - CLINDAMYCIN PREMIX 300 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-3612-24 - CLINDAMYCIN PREMIX 600 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-3814-24 - CLINDAMYCIN PREMIX 900 MG/DEXTROSE 5% 50 ML [JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-9545-24 - clindamycin 300 mg/50 mL-NaCl 0.9% Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00338-9553-24 - CLINDAMYCIN PREMIX 900 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-0614-01 - THIORIDAZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-0871-99 - cloNIDine 0.1 MG/24  HR PATCH (BI 31) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-0872-99 - cloNIDine 0.2 MG/24 HR PATCH (BI 32) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-0873-99 - cloNIDine 0.3 MG/24 HR PATCH (BI 33) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-2100-01 - LOPERAMIDE HCL 2 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-3065-77 - FENOFIBRATE 48 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-3066-77 - FENOFIBRATE 145 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-6992-52 - RT ALBUTEROL 1.25 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-6993-93 - RT LEVALBUTEROL 1.25 MG/0.5 ML INHALATION SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-8270-52 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-8270-55 - RT ALBUTEROL 2.5  MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9104-93 - NITROGLYCERIN 0.2 MG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9112-93 - NITROGLYCERIN 0.4 MG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9116-93 - NITROGLYCERIN 0.6 MG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9119-98 - fentaNYL 12 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9320-32 - FLUTICASONE/SALMETEROL 100/50 MCG INHALATION POWDER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9321-32 - FLUTICASONE/SALMETEROL 250/50 MCG INHALATION POWDER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9671-93 - RT IPRATROPIUM-ALBUTEROL 0.5 MG/3 MG PER 3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00378-9692-52 - RT LEVALBUTEROL 1.25 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00386-0001-11 - ETHYL CHLORIDE TOPICAL ANESTHETIC [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00395-0073-92 - AMMONIA SPIRIT INHALATION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00395-0247-92 - BENZOIN COMPOUND TINCTURE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00395-2015-91 - PEPPERMINT OIL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0123-62 - HYDROcodone-ACETAMINOPHEN 5-325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0124-62 - HYDROcodone-ACETAMINOPHEN 7.5-325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0125-62 - HYDROcodone-ACETAMINOPHEN 10-325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0484-62 - ACETAMINOPHEN/CODEINE 300/30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0484-62 - CODEINE/ACETAMINOPHEN 300/30 MG TAB **TH JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0512-62 - OXYCODONE/APAP 5/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-0523-62 - oxyCOCONE/ACETAMINOPHEN 10/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-5771-62 - METHADONE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-8315-62 - MORPHINE ER 15 MG (8-12 HR) TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-9100-76 - fentaNYL TRANSDERMAL SYSTEM PATCH 100 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-9112-76 - fentaNYL TRANSDERMAL SYSTEM 12 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-9125-76 - fentaNYL 25 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00406-9961-01 - TEMAZEPAM 15 MG  CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00407-1413-63 - IOHEXOL 300 MG/ML (100 ML),,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00407-1414-91 - IOHEXOL 350 MGI/ML INJ (100 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00407-1414-93 - IOHEXOL 350 MGI/ML INJ (150 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-0152-24 - metroNIDAZOLE PREMIX 500 MG/100 ML [JSHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-0528-31 - levoFLOXacin PREMIX 750 MG/150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-0528-35 - levoFLOXacin PREMIX 750 MG/150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1162-02 - BUPIVACAINE 0.5% PRESERVATIVE-FREE 150 MG/30 ML INJ (SDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1162-10 - BUPIVACAINE-MPF 0.5% INJ - 30 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1207-15 - GENTAMICIN 80 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1215-01 - NALOXONE 0.4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1283-37 - DILAUDID 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1330-01 - DOXERCALCIFEROL 4 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1412-04 - BUMETANIDE 1 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1463-01 - NALBUPHINE 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1463-49 - NALBUPHINE 10 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1610-50 - BUPivacaine 0.5% 250 MG/50 ML INJ (MDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1630-10 - ATROPINE 1 MG/10 ML INJ (SYRINGE) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1632-01 - VECURONIUM 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1761-02 - BUPIVACAINE SPINAL INJ - 2 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1775-10 - DEXTROSE 25% 2.5 GM/10 ML INJ (INFANT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1778-05 - METOPROLOL 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-1985-30 - LORazepam 2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2267-20 - LABETALOL 100 MG/20 ML INJ (MDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2305-05 - MIDAZOLAM 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2305-17 - MIDAZOLAM 2 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2305-55 - MIDAZOLAM 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2346-32 - DOBUTamine 250 MG/250 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-2596-05 - MIDAZOLAM 50 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3178-16 - LIDOCAINE W/EPI 1% INJ 20 ML MDV [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3300-24 - CIPROFLOXACIN PREMIX 400MG/ 200ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3308-03 - ACETYLCYSTEINE 20% 6000 MG/30 ML SOLUTION **INAHALATION** [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3375-04 - NOREPINEPHRINE 4 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3414-01 - METOCLOPRAMIDE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3718-01 - AMPICILLIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3795-01 - KETOROLAC 30 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-3796-01 - KETOROLAC 60 MG/2 ML INJ [JDHS],26039,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4283-01 - LIDOCAINE 4% INJ 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00409-4520-30 - HEPARIN PREMIX 25,000 UNITS IN DEXTROSE 5% 250 ML [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4777-23 - CIPROFLOXACIN PREMIX 200 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4887-10 - STERILE WATER FOR INJECTION 10 ML,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4887-20 - STERILE WATER FOR INJ 20 ML (DILUENT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4888-10 - SODIUM CHLORIDE 0.9% FOR INJECTION 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4888-20 - SODIUM CHLORIDE 0.9% FOR INJECTION 20 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4902-34 - DEXTROSE 50% 50 ML INJ (ADULT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4903-34 - LIDOCAINE 2% (CARDIAC) 100 MG/5 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-4933-01 - EPINEPHrine 1 MG/10 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-5534-14 - SODIUM BICARBONATE 4.2% 5 MEQ/10 ML SYRINGE (INFANT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-5534-34 - SODIUM BICARB 4.2% 5 MEQ/10 ML INJ (INFANT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-6102-04 - FUROSEMIDE 40 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-6102-26 - FUROSEMIDE 40 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-6533-21 - VANCOMYCIN 1000 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-6635-01 - POT CHLORIDE 10 MEQ/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-6637-14 - SODIUM BICARB 8.4% 50 MEQ/50 ML INJ (ADULT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7295-01 - POTASSIUM PHOSPHATES 45 mmol/15 ML INJ  (with potassium 66 mEq/15 mL) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7299-73 - SODIUM ACETATE 40 meq/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7332-20 - cefTRIAXone 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7335-20 - cefTRIAXone 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7337-20 - cefTRIAXone 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7338-20 - cefTRIAXone 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7517-16 - DEXTROSE 50% 25 GM/50 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00409-7650-62 - HEPARIN PREMIX 25,000 UNITS in SODIUM CHLORIDE 0.45% 250 ML [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7809-22 - DOPamine 400 MG/250 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-7811-37 - metroNIDAZOLE PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9093-35 - fentaNYL 250 MCG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9094-22 - fentaNYL 100 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9094-25 - fentaNYL 250 MCG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9094-31 - fentaNYL 1000 MCG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9157-01 - PHYTONADIONE NEONATE 1 MG/0.5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9158-01 - PHYTONADIONE 10 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00409-9558-50 - ROCURONIUM 100 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00436-0936-16 - SODIUM HYPOCHLORITE 0.25% 1/2 STRENGTH SOLUTION 473 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00456-0600-01 - CEFTAROLINE 600 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00456-0600-10 - CEFTAROLINE 600 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00456-1201-30 - linaCLOtide 145 MCG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00456-1203-30 - linaCLOtide 72 MCG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00456-1405-30 - NEBIVOLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00469-3211-10 - MICAFUNGIN 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00472-0337-30 - HYDROCORTISONE 2.5% CREAM 30 GM [JDSH],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00480-3310-01 - THEOPHYLLINE ER 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-0201-01 - RT IPRATROPIUM/ALBUTEROL 0.5 MG/3 MG PER 3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-0201-03 - RT IPRATROPIUM/ALBUTEROL 0.5/3 MG PER 3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-0301-01 - RT ALBUTEROL 0.63 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-2784-01 - RT RACEPINEPHRINE 2.25% 11.25 MG/0.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-5901-99 - RT RACEPINEPHRINE 2.25% 11.25 MG/0.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9003-60 - RT SODIUM CHL 3% INHALATION SOLN 4 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9302-01 - RT SODIUM CHL 0.9% INHALATION SOL 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9501-03 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9501-25 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9701-01 - RT BUDESONIDE 0.5 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9901-30 - RT ALBUTEROL 2.5 MG/0.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00487-9904-01 - ALBUTEROL 1.25 MG/3 ML (0.042%) INHALATION SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00496-0523-06 - Miscellaneous MAR Items - Liquid,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-0031-25 - CYANOCOBALAMIN 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-0374-05 - METHYLENE BLUE 0.5% 50 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-0401-25 - ATROPINE 0.4 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-0650-01 - FERRIC CARBOXYMALTOSE 750 MG/15 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-0710-01 - FOMEPIZOLE 1.5 GM/1.5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-1004-25 - ATROPINE 0.4 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-1980-05 - DICYCLOMINE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-2340-10 - IRON SUCROSE INJ 100 MG/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-5601-25 - hydrOXYzine 50 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-7604-25 - RT ACETYLCYSTEINE FOR INHALATION 20% 800 MG/4 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00517-9702-25 - DROPERIDOL 5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00527-1930-06 - CLARITHROMYCIN ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00527-6004-80 - LIDOCAINE 4% TOPICAL SOLUTION 40 MG/ML (50 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-0015-83 - ALUMINUM/MAGNESIUM/SIMETHICONE 1200/1200/120 MG PER 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1054-29 - ASPIRIN 325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1161-37 - guaiFENesin/DEXTROMETHORPHAN 30/600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1211-95 - DIBUCAINE 1% OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1224-97 - EYE WASH IRRIGATING SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1228-58 - PHENOL 1.4% ORAL ANESTHETIC SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1234-41 - ASPIRIN EC 81 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1266-59 - SENNOSIDES 8.8 MG/5 ML SYRUP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1303-75 - SIMETHICONE DROPS 20 MG/0.3 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1313-85 - GUAIFENESIN/DEXTROMETHORPHAN 200/20 MG PER 10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1316-28 - ZINC OXIDE OINTMENT 20% [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-1327-10 - ACETAMINOPHEN 325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-4306-11 - CALCIUM POLYCARBOPHIL 625 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00536-5700-28 - ZINC OXICE 20% OINTMENT 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00548-5850-00 - GLUCAGON KIT 1 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00555-0033-02 - chlordiazePOXIDE 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00555-0071-02 - ISONIAZID 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00555-0159-02 - chlordiazePOXIDE 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00555-0779-02 - MEDROXYPROGESTERONE ACETATE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00555-0886-02 - ESTRADIOL 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0107-70 - CLOTRIMAZOLE TROCHE 10 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0520-04 - CHARCOAL-SORBITOL 25 GM/120 ML SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0520-74 - CHARCOAL/SORBITOL 25 GM/120 ML SUSPENSION [JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0521-74 - CHARCOAL AQUEOUS SUSP 25 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0608-01 - FERROUS SULF EC 324 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-0691-05 - GLUTOSE 15 ORAL GEL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-4024-35 - ERYTHROMYCIN 3.5 GM OPTH OINT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-7034-12 - ASPIRIN 300 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-7050-12 - BISACODYL 10 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00574-7090-12 - HYDROCORTISONE 25 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-0240-01 - LORazepam 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-0347-01 - HYDROCHLOROTHIAZIDE 12.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-0348-01 - TRIAMTERENE/HCTZ 75/50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-2136-95 - PROPOFOL 200 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-3525-30 - LIDOCAINE 5% PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-3546-01 - BUTALBITAL/ASP/CAFF/COD 50/325/40/30 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00591-3875-44 - MEMANTINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00597-0024-02 - IPRATROPIUM BROMIDE/ALBUTEROL 20/100 MCG INHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00597-0075-75 - TIOTROPIUM HANDIHALER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00597-0260-10 - GLUCAGON KIT 1 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00603-5483-21 - PROPRANOLOL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-0376-25 - diphenhydrAMINE 50 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-0476-25 - PHENobarbital 65 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-0493-25 - PHENYTOIN 100 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-0928-25 - PROMETHAZINE 25 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-1397-35 - chlorproMAZINE 25 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-1410-35 - DIGOXIN 0.5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-2555-45 - PHENYTOIN 250 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6013-10 - dilTIAZem 25 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6014-10 - dilTIAZem 50  MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6015-10 - dilTIAZem 5 mg/mL Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6015-10 - dilTIAZem 125 MG/25 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6018-06 - DOXAPRAM 400 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6022-25 - FAMOTIDINE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6027-25 - fentaNYL 100 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6044-25 - LORazepam 2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6048-25 - LORazepam 2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6052-25 - MEPERIDINE 25 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6053-25 - MEPERIDINE 50 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6057-25 - MIDAZOLAM 2 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6059-10 - MIDAZOLAM 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6060-10 - MIDAZOLAM 50 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6080-25 - ONDANSETRON 4 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6116-10 - AMPICILLIN-SULBACTAM 1.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6117-10 - AMPICILLIN/ SULBACTAM 3 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6125-25 - MORPHINE 4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6132-25 - NALOXONE 0.4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6135-25 - PROCHLORPERAZINE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6137-10 - FOSPHENYTOIN MGPE/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6138-25 - PHENYTOIN SODIUM 100 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6139-25 - PHENYTOIN 250 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6145-25 - dexAMETHasone 4 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6147-25 - STERILE WATER FOR INJ 10 ML (DILUENT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6161-01 - BUMETANIDE 1 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6175-10 - OCTREOTIDE 100 MCG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6182-10 - ORPHENADRINE 60 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6184-25 - DIGOXIN 0.5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6190-10 - MIDAZOLAM 50 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6208-25 - PROMETHAZINE 25 mg/mL Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6228-25 - VITAMIN B-1 200 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-6231-25 - hydrALAZINE 20 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-9217-10 - dilTIAZem 25 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-9219-01 - diltiaZEM 125 MG/25 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00641-9219-10 - diltiaZEM 25 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00703-0241-01 - TRIAMCINOLONE ACET 40 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00703-3311-04 - OCTREOTIDE 100 MCG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0225-31 - TRIAMCINOLONE 0.1% CRAM 30 GM (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0280-31 - BACITRACIN TOP OINT 500 UNITS/GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0351-09 - PROCHLORPERAZINE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0503-12 - HYDROCORTISONE ACETATE 25 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0536-12 - PROMETHAZINE 12.5 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0632-15 - FLUTICASONE PROPIONATE 0.005% OINTMENT 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0634-15 - MOMETASONE 0.1% CREAM 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0682-15 - GENTAMICIN 0.1% OINTMENT 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0682-31 - GENTAMICIN 0.1% OINTMENT 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00713-0683-31 - GENTAMICIN 0.1% CREAM 30 GM (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00713-0686-15 - NYSTATIN OINT 100,000 UNITS/GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-1061-01 - ALPRAZolam 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-1061-05 - ALPRAZolam 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-1079-01 - ALPRAZolam 1 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3059-95 - DIGOXIN 0.5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3154-01 - FERUMOXYTOL 510 MG/17 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3156-95 - ACETAMINOPHEN 1000 MG/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3206-95 - cefTRIAXone 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3232-95 - PANTOPRAZOLE 40 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3289-09 - CLINDAMYCIN PREMIX 600 MG/50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3402-95 - AMPICILLIN 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3422-92 - PHENYLEPHRINE 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3440-95 - COSYNTROPIN 0.25 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-3755-95 - NOREPINEPHRINE 4 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-6023-52 - CLARITHROMYCIN 250 MG/5 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-6039-46 - AMOXICILLIN 125 MG/5 ML ORAL SUSP 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-6160-86 - SEVOFLURANE ANESTHETIC INH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-9210-95 - PIPERACILLIN/TAZOBACTAM 2.25 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-9213-95 - PIPERACILLIN-TAZOBACTAM 3.375 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-9214-95 - PIPERACILLIN-TAZOBACTAM 4.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-9404-95 - AMPICILLIN 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00781-9408-95 - AMPICILLIN 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00799-0001-02 - MENTHOL/ZINC OXIDE 0.44/20.6% OINT TUBE 71 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00799-0001-03 - MENTHOL/ZINC OXIDE 0.44/20.6% OINT JAR 71 G [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00799-0001-05 - MENTHOL/ZINC OXIDE 0.44%/6% OINTMENT PACKET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-0111-00 - AMANTADINE HCL 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-0111-03 - AMANTADINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"00832-0465-15 - NYSTATIN 100,000 UNITS/GM TOPICAL POWDER 15 GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-0590-11 - DIPHENOXYLATE/ATROPINE 2.5/0.025 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1211-01 - WARFARIN 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1212-01 - WARFARIN 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1213-01 - WARFARIN 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1214-01 - WARFARIN 3 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1216-01 - WARFARIN 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-1218-01 - WARFARIN 7.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-7123-01 - DIVALPROEX SOD DR 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-7124-01 - DIVALPROEX SOD DR 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00832-7124-89 - DIVALPROEX SOD DR 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00869-0166-38 - MAGNESIUM CITRATE 1.745 G/30 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-0430-06 - DOXYCYCLINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-0523-61 - ASCORBIC ACID 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-0523-72 - VITAMIN C 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-1453-61 - metroNIDAZOLE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-2056-61 - diphenhydrAMINE 50 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-2500-91 - CALCIUM POLYCARBOPHIL 625 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-2725-61 - SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-3854-61 - carBAMazepine 100 MG CHEW TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5053-59 - PSEUDOEPHEDRINE 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5282-61 - RIFAMPIN 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5306-61 - diphenhydrAMINE 25 mg Cap UD [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5395-61 - POLYSACCHARIDE IRON COMPLEX 150 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5492-61 - multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab UD [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5523-61 - DOXAZOSIN 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5610-61 - ENALAPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5677-61 - PARoxetine 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5784-61 - FLUoxetine 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5785-61 - FLUoxetine 20 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5789-61 - ACYCLOVIR 200 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5790-61 - ACYCLOVIR 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5853-61 - IBUPROFEN 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5854-61 - IBUPROFEN 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5855-61 - IBUPROFEN 800 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5921-61 - DIGOXIN 0.125 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-5959-61 - CLINDAMYCIN 150 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6007-61 - LORazepam 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6008-61 - LORazepam 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6051-61 - levETIRAcetam 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6082-61 - ZOLPIDEM 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6085-61 - CITALOPRAM 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6172-61 - carBAMazepine 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6187-61 - PHENYTOIN SOD EXTENDED 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6237-61 - CARBIDOPA/ LEVODOPA 25/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6238-61 - CARBIDOPA/LEVODOPA 25/250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6255-49 - BENZOCAINE/MENTHOL 15/3.6 MG LOZENGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6269-45 - ZIPRASIDONE 20 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6291-61 - ATORVASTATIN 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6292-61 - ATORVASTATIN 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6294-61 - CLOPIDOGREL 75 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6300-61 - CARVEDILOL 3.125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6301-61 - CARVEDILOL 6.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6302-61 - CARVEDILOL 12.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6305-21 - PHENOL 1.4% ORAL ANESTHETIC SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6322-61 - METOPROLOL SUCC ER 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6323-61 - METOPROLOL SUCC ER 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6351-61 - LevoFLOXACIN 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6357-61 - risperiDONE 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6358-61 - risperiDONE 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6359-61 - risperiDONE 1 MG tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6360-61 - risperiDONE 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6363-61 - DIVALPROEX SOD ER 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6364-61 - DIVALPROEX SOD ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6370-61 - AmLODIPine 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6373-61 - rOPINIRole 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6374-61 - rOPINIRole 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6407-61 - BISACODYL EC DR 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6412-92 - CALCIUM CARB 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6418-61 - tiZANidine 4 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6426-61 - ESCITALOPRAM 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6441-61 - hydrALAZINE HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6449-61 - ISOSORBIDE MONO ER 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6461-61 - PROMETHAZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6468-61 - VENLAFAXINE ER 37.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6469-61 - VENLAFAXINE ER 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6475-61 - BACLOFEN 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6477-61 - DONEPEZIL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6488-38 - ARTIFICIAL TEARS OPTH OINTMENT 3.5 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6500-06 - FLUCONAZOLE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6502-61 - CELECOXIB 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6506-61 - MEMANTINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6517-61 - MECLIZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6522-61 - SENNOSIDES 8.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6557-61 - MORPHINE ER 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6558-61 - MORPHINE ER 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6564-61 - BENZONATATE 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6570-61 - oxyBUTYnin ER 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6585-61 - buPROPion SR 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6617-61 - hydrOXYzine HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6637-61 - glipiZIDE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6638-61 - QUEtiapine 25 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6640-61 - QUEtiapine 100 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6642-61 - QUEtiapine 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6665-61 - GABAPENTIN 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6666-61 - GABAPENTIN 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6667-61 - GABAPENTIN 400 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6671-04 - SILDENAFIL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6705-06 - PROPRANOLOL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6705-61 - PROPRANOLOL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6708-06 - AZITHROMYCIN 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6717-61 - CETIRIZINE TAB 10 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6718-39 - guaiFENesin ER 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6730-61 - ACETAMINOPHEN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6741-72 - diphendydrAMINE 25 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6773-61 - ACETAMINOPHEN 325 MG TAB [JDHS],10572888,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6782-61 - HALOPERIDOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6787-44 - MAGNESIUM CITRATE ORAL SOLUTION 10 OZ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6790-61 - BENZTROPINE MESYLATE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6794-80 - ASPIRIN CHEW 81 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6794-89 - ASPIRIN CHEW 81 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6797-61 - LISINOPRIL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6799-61 - LISINOPRIL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6808-06 - MONTELUKAST 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6825-61 - HYDROcodone/APAP 10/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6826-61 - HYDROcodone/APAP 7.5/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6830-06 - FINASTERIDE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6836-20 - LOPERAMIDE 2 MG/15 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6860-61 - DIVALPROEX SOD DR 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6861-61 - DIVALPROEX SOD DR 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6868-61 - traZODone 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6870-45 - PANTOPRAZOLE DR 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6888-06 - MINOCYCLINE 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6923-61 - predniSONE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6925-61 - SERTRALINE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6927-61 - SPIRONOLACTONE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6930-61 - POTASSIUM CHLORIDE ER 10 MEQ CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6931-86 - POLYETHYLENE GLYCOL POWDER 17 GM PACKET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6938-06 - acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6950-61 - LEVOTHYROXINE 50 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6952-61 - LEVOTHYROXINE 88 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6954-61 - LEVOTHYROXINE 112 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6955-61 - LEVOTHYROXINE 125 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6980-72 - guaiFENesin/DEXTROMETHORPHAN 200/20 MG PER 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6988-61 - DICYCLOMINE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6990-61 - PSEUDOEPHEDRINE 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6992-61 - PREGABALIN 50 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6993-61 - AMIODARONE HCL 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-6998-60 - DOCUSATE SODIUM 100 MG CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7006-35 - OXYMETAZOLINE 0.05% NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7008-61 - LamoTRIGINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7016-61 - BUMETANIDE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7044-61 - DULoxetine DR 30 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7045-61 - DULoxetine 60 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7046-06 - Hydroxychloroquine 200 MG Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7047-61 - LOSARTAN POTASSIUM 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7048-61 - LOSARTAN POTASSIUM 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7053-61 - DOXEPIN 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7057-61 - METHOCARBAMOL 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7061-87 - POTASSIUM CHLORIDE 10% 20 MEQ/15 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7065-61 - hydrOXYzine PAMOATE 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7077-61 - VENLAFAXINE ER 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7083-61 - CIPROFLOXACIN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7084-04 - buPROPion ER (XL) 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7095-61 - oxyCODONE-ACETAMINOPHEN 10-325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7109-61 - LABETALOL 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7121-61 - busPIRone 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7122-61 - busPIRone 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7124-61 - levETIRAcetam 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7135-72 - guaiFENesin-DEXTROMETHORPHAN 200-20 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7156-61 - metroNIDAZOLE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7161-04 - FENOFIBRATE 145 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7162-61 - metFORMIN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7163-61 - metFORMIN 850  MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7179-61 - traMADol 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7183-61 - DOCUSATE SODIUM 100 MG CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7189-04 - NEBIVOLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7193-61 - FAMOTIDINE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7205-46 - bismuth subsalicylate 262 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7208-61 - NIFEdipine er 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7212-61 - traZODone 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7214-61 - buPROPion SR 150 mg/12 hours Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7218-61 - dilTIAZem ER 180 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7237-61 - diphenhydrAMINE 25 mg Cap,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7243-61 - CIPROFLOXACIN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7252-60 - SENNOSIDES 8.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7257-61 - CARBIDOPA/LEVODOPA 25/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-7279-72 - docusate 10 mg/mL Liq,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00904-8805-67 - NEOMYCIN/POLYMIXIN B SULF/BACITRACIN ZINC OINTMENT PACKET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00944-0493-02 - ALBUMIN HUMAN PREMIX 25% 25 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7075-26 - POTASSIUM CHL (PREMIX) 20 MEQ/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7077-26 - POTASSIUM CHL (PREMIX) 40 MEQ/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7109-09 - IV D5 NS W/40 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7115-09 - IV NS W/20 MEQ KCL 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7715-03 - MANNITOL 20% PREMIX 100 GM/500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7715-13 - MANNITOL 20% - 500 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7923-13 - IV DEXTROSE 5% 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7923-23 - IV DEXTROSE 5% 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7923-37 - IV D5W 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7926-09 - IV D5 1/2 NS 1000 ML [JDHS],,CDM,258,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7953-09 - IV LACTATED RINGERS 1000 ML (LR) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7983-09 - IV NS 1000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7984-13 - IV SODIUM CHLORIDE 0.9% 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7984-23 - IV NS 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00990-7993-09 - LVP solution with potassium Dextrose 5% with 0.45% NaCl and KCl 10 mEq/L Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
08290-3064-24 - HEPARIN LOCK FLUSH 500 UNITS/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
08290-3065-44 - SODIUM CHLORIDE 0.9% FLUSH 3 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
08290-3065-46 - SODIUM CHLORIDE 0.9% FLUSH 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
08327-0309-09 - SILVER TOPICAL GEL 45 ML (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
08833-3344-01 - Cavilon Barrier Film Liquid [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
09958-0340-00 - MEDIHONEY WOUND/BURN GEL 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10006-0700-28 - MAGNESIUM OXIDE 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10019-0360-40 - ISOFLURANE LIQUID FOR INHALATION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10019-0641-34 - DESFLURANE LIQUID FOR INHALATION ANESTHETIC [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10019-0644-34 - DESFLURANE INHALATION ANESTHETIC [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10019-0651-64 - SEVOFLURANE FOR INHALATION ANESTHETIC [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10119-0002-52 - EYE IRRIGATING SOLUTION 118 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10135-0666-01 - PRAZOSIN HCL 1 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10135-0705-50 - LACTOBACILLUS/ACIDOPHILUS/BULGARICUS TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10135-0708-01 - cloNIDine HCL 0.1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10135-0729-62 - ASPIRIN EC 81 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"10223-0201-04 - BENZOCAINE 14%,BUTAMBEN 2%,TETRACAINE HCL 2% TOP ANES SPRAY [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10702-0253-01 - BUTALBITAL/APAP/CAFFEINE 50/325/40 MG TAB (FIORICET) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11523-7268-03 - POLYETHYLENE GLYCOL POWDER 17 GM PACKET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11534-0165-01 - FOLIC ACID 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11701-0002-38 - SWEEN CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11701-0059-05 - PERI-WASH II [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
12547-1504-00 - WITCH HAZEL HEMORRHOIDAL PADS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
12547-4930-09 - ARTIFICIAL TEARS 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
12870-0001-02 - SILVER NITRATE STICK [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13517-0693-01 - PHENobarbital 60 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13517-0757-01 - PHENobarbital 60 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13533-0131-01 - TETANUS/DIPHTHERIA TOXOIDS ABSORBED 0.5 ML INJ (7 YRS & OLDER) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13668-0008-01 - ZOLPIDEM 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13668-0010-01 - CITALOPRAM 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13668-0086-30 - OLANZAPINE ODT 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13668-0093-90 - PRAMIPEXOLE 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
13668-0189-30 - TOLTERODINE TARTRATE ER 2 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16571-0778-09 - DONEPEZIL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0006-10 - ENOXAPARIN 30 MG/0.3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0007-01 - ISOSORBIDE DINITRATE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0009-01 - ISOSORBIDE DINITRATE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0014-01 - AMOXICILLIN/CLAV POT 875/125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0015-01 - DESMOPRESSIN ACETATE 40 MCG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0018-30 - RT BUDESONIDE 0.25 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0019-30 - RT BUDESONIDE 0.5 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0020-30 - RT BUDESONIDE 1 MG/2 ML INHALATION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0026-10 - ENOXAPARIN 60 MG/0.6 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0036-10 - ENOXAPARIN 80 MG/0.8  ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0039-01 - COLCHICINE 0.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0046-10 - ENOXAPARIN 100 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0048-01 - chlorproMAZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0050-01 - chlorproMAZINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0056-10 - ENOXAPARIN 120 MG/0.8 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0066-10 - ENOXAPARIN 150 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0081-10 - hydrOXYzine HCL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0097-01 - LIDOCAINE VISCOUS 2% OS 100 ML BOTTLE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0110-01 - HYDROXYCHLOROQUINE 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0128-01 - CHLORTHALIDONE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0130-25 - TRIAMCINOLONE ACET 40 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0141-01 - ARIPiprazole 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0142-01 - ARIPiprazole 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0143-01 - ARIPiprazole 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0177-30 - LIDOCAINE 5% PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0200-30 - ONDANSETRON TAB 4 MG ODT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0200-30 - ONDANSETRON ODT 4 MG TAB **TH,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0201-30 - ONDANSETRON ODT 8 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0257-01 - AMITRIPTYLINE HCL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0293-01 - AMOXICILLIN/CLAV POT 400 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0293-02 - AMOXICILLIN/CLAVULANATE 400/57 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0294-01 - AMOXICILLIN/CLAV POT ES 600 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0298-01 - AMOXICILLIN 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0299-03 - AMOXICILLIN 500 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0389-01 - CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0391-02 - CEFDINIR 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0394-01 - CEFPODOXIME 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0400-01 - CEFUROXIME 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0442-01 - ENALAPRIL 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0477-01 - AMOXICILLIN/CLAV POT 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0483-01 - CLINDAMYCIN PALMITATE HCL 75 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0496-01 - CLOTRIMAZOLE/BETAMETHASONE DIP CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0528-10 - PROPOFOL 200 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0529-01 - BISOPROLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0534-01 - EMTRICITABINE-TENOFOVIR 200-300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0591-01 - DIGOXIN 0.25 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0612-01 - SERTRALINE 50 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0621-01 - ZOLPIDEM 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0622-01 - ZOLPIDEM 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0633-01 - ALENDRONATE 70 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0661-01 - GABAPENTIN 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0662-01 - GABAPENTIN 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0692-11 - FLUCONAZOLE 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0695-01 - FLUCONAZOLE 10 MG/1 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0698-03 - valACYclovir 500 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0732-01 - CELECOXIB 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0769-01 - NYSTATIN TOPICAL POWDER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"16714-0769-02 - NYSTATIN 100,000 UNITS/G POWDER 30 GM (WC) [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0796-01 - SUMAtriptan 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0813-02 - EZETIMIBE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0835-01 - ZIPRASIDONE 20 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0836-01 - ZIPRASIDONE 40 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0837-01 - ZIPRASIDONE 60 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0838-01 - ZIPRASIDONE 80 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0878-01 - LIDOCAINE 5% OINTMENT 35.44 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0894-01 - glipiZIDE ER 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0895-01 - glipiZIDE ER (XL) 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0897-01 - PERMETHRIN 5% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0899-02 - FEXOFENADINE 180 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0955-01 - KETOCONAZOLE 2% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0964-01 - ASA/DIPYRIDAMOLE 25/200 mg CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0974-01 - MOMETASONE FUROATE 0.1% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0986-01 - TRIAMCINOLONE 0.1% CREAM 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16714-0986-02 - TRIAMCNOLONE 0.1% CREAM 30 GM (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0003-01 - GLIMEPIRIDE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0020-15 - PIOGLITAZONE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0079-01 - CARBIDOPA/LEVODOPA ER 50/200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0090-01 - FINASTERIDE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0137-00 - ClonaZEPAM 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0171-01 - AMITRIPTYLINE HCL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0183-01 - HYDROCHLOROTHIAZIDE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0278-01 - ARIPiprazole 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0279-01 - ARIPiprazole 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0321-15 - OLMESARTAN MEDOXOMIL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0464-08 - PHENYLEPHRINE 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0500-08 - FUROSEMIDE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0501-43 - FUROSEMIDE 40 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16729-0525-08 - ATROPINE 0.4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
16864-0670-01 - BENZETHONIUM CHL-BENZOCAINE 0.2%-20% SPRAY (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17238-0900-11 - FLUORESCEIN SOD 1 MG OPHTH STRIP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17238-0900-30 - FLUORESCEIN SOD 1.0 MG OPTH STRIP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17271-0701-02 - IV NS 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0070-35 - ERYTHROMYCIN 0.5% OPTH OINTMENT 3.5 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0171-30 - RT LEVALBUTEROL 1.25 MG/0.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0284-35 - GENTAMICIN 0.3% OPTH OINT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0290-10 - TOBRAMYCIN 0.3% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0538-02 - ORPHENADRINE 60 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0542-02 - ADENOSINE 6 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0542-25 - ADENOSINE 6 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0719-35 - NEOMYCIN/POLYMYXIN B/BACITRACIN/HYDROCORTISONE OPTH OINT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17478-0934-01 - hydrALAZINE 20 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
19903-0102-01 - SIMETHICONE DROPS 20 MG/0.3 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
20555-0017-00 - CALCIUM W/VITAMIN D 600 MG/400 IU TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
20555-0330-00 - cholecalciferol 1000 IU (25 MCG) TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
21922-0009-09 - DICLOFENAC 1% GEL 100 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0024-01 - busPIRone 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0057-01 - glyBURIDE 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0071-01 - methIMAzole 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0191-01 - buPROPion 75 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0192-01 - buPROPion 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0194-01 - NIFEdipine 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0313-31 - acetaZOLAMIDE 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0473-41 - FUROSEMIDE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0473-42 - FUROSEMIDE 40 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0497-42 - PROCHLORPERAZINE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0600-41 - MIDAZOLAM 2 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0605-03 - MODAFINIL 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
23155-0772-01 - ENALAPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24201-0100-24 - ACETAMINOPHEN PREMIX 1000 MG/100 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0315-10 - POLYMYXIN B SULF-TRIMETHOPRIM 10000 U-1 MG PER ML OPTH SOLUTION 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0410-10 - OFLOXACIN 0.3% OTIC SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0411-05 - BRIMONIDINE 0.2% OPTH DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0580-60 - GENTAMICIN 0.3% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0631-10 - NEOMYCIN/POLYMIXIN B/HYDROCORTISONE OTIC SOLUTION 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0670-04 - SULFACETAMIDE SOD 10% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"24208-0785-55 - NEOMYCIN-POLYMYXIN B SULF-BACITRACIN ZINC-HYDORCORTISONE 3.5 MG-10,000 U-400 U-10 MG",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
24208-0910-55 - ERYTHROMYCIN 0.5% OPTH OINTMENT 3.5 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0109-10 - ceFOXitin 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0110-20 - ceFOXitin 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0114-87 - CIPROFLOXACIN PREMIX 400 MG/200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0127-20 - cefTAZidime 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0128-50 - cefTAZidime 2 GM INJ  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0132-81 - LevoFLOXACIN 250 MG/50 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0139-10 - NAFCILLIN 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0142-20 - AMPICILLIN/ SULBACTAM 1.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0184-66 - FLUCONAZOLE PREMIX 200 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0184-82 - FLUCONAZOLE PREMIX 200 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0191-10 - MICAFUNGIN 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0500-02 - VITAMIN B-1 200 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0673-76 - LIDOCAINE 2% JELLY 6 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0812-30 - ACETYLCYSTEINE 20% 6000 MG/30 ML **INJECTION**,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
25021-0826-82 - ZOLEDRONIC ACID 4 MG/100 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
27241-0139-09 - OSELTAMIVIR PHOSPHATE 6 MG/1 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
27808-0065-02 - PROMETHAZINE/CODEINE 6.25/10 MG PER 5 ML SYRUP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
28595-0120-49 - NITROGLYCERIN SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
29033-0003-01 - SUCRALFATE 1 GM TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
29300-0126-01 - BISOPROLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
29300-0190-19 - LOSARTAN POT/HCT 50/12.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0131-30 - DUTASTERIDE 0.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0152-90 - VALSARTAN 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0153-90 - VALSARTAN 160 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0506-60 - LAMIVUDINE/ZIDOVUDINE 150/300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0531-01 - TORSEMIDE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0532-01 - TORSEMIDE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0586-30 - NEBIVOLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0632-31 - OSELTAMIVIR 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0681-47 - ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0727-30 - MONTELUKAST 4 MG CHEWABLE TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0727-90 - MONTELUKAST 4 MG CHEWABLE TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0730-90 - IRBESARTAN 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0749-20 - LINEXOLID 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
31722-0777-01 - ACYCLOVIR 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
32909-0741-03 - BARIUM SULFATE ORAL SUSP 2% W/V BERRY SMOOTHIE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33342-0088-41 - RIZATRIPTAN 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33342-0089-09 - RIVASTIGMIN 1.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33342-0090-09 - RIVASTIGMINE 3 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33342-0091-09 - RIVASTIGMINE 4.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
33342-0110-07 - MONTELUKAST 4 MG CHEWABLE TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
35573-0445-25 - RT LEVALBUTEROL 1.25 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0008-24 - CIPROFLOXACIN PREMIX 200 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0009-24 - CIPROFLOXACIN PREMIX 400 MG/200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0033-10 - METOPROLOL 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0148-10 - FLUMAZENIL 0.5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0244-25 - TOBRAMYCIN 80 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0282-25 - FUROSEMIDE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0283-25 - FUROSEMIDE 40 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36000-0322-02 - LABETALOL 100 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
37000-0024-04 - PSYLLIUM 5.8 GM PACKET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
39328-0057-50 - IRON SUPPLEMENT 15 MG/1 ML DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
39328-0063-25 - DAKINS SOLUTION HALF STRENGTH 0.25% [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
39822-0190-01 - acetaZOLAMIDE 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
39822-1100-01 - FOLIC ACID INJ 5 MG/ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
39822-5525-03 - PROMETHAZINE 25 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
40565-0122-49 - CADEXOMER IODIONE GEL 0.9% GEL 40 GM (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
41100-8112-01 - OXYMETAZOLINE 0.05% NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
41167-5800-03 - TRIAMCINOLONE NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
41388-0007-30 - WITCH HAZEL 50% HEMORRHOIDAL PADS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"42023-0104-01 - TUBERCULIN, PURIFIED PROTEIN DERIVATIVE, DILUTED 5 TU/0.1 ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0116-25 - OXYTOCIN 10 UNITS/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0159-25 - EPINEPHrine 1 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0164-25 - VASOPRESSIN 20 units/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0168-99 - EPINEPHrine 1 MG/1 ML (30 ML MDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0189-10 - NEOSTIGMINE 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0201-01 - LEVOTHYROXINE 100 MCG *INJECTION* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0216-25 - ePHEDrine 50 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42023-0219-10 - VASOPRESSIN PREMIX 40 UNITS/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42037-0104-79 - CARBAMIDE PEROXIDE OTIC 6.5% SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42043-0220-09 - SUMAtriptan 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42192-0605-10 - TRANEXAMIC ACID 1000 MG/10 ML *IVPush* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42192-0614-30 - PHENYTOIN 250 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42291-0465-01 - CARBIDOPA/LEVODOPA 10/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42291-0562-90 - MIDODRINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42291-0773-60 - RANOLAZINE ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42291-0898-90 - VENLAFAXINE ER 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42292-0003-20 - DIGOXIN 0.125 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42292-0038-20 - LEVOTHYROXINE 88 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42367-0570-87 - VASOPRESSIN 20 units/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42571-0141-26 - DORZOLAMIDE 2% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42571-0161-01 - AMOXICILLIN/CLAVULANATE 500/125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42658-0122-04 - IRBESARTAN 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42799-0806-01 - IVERMECTIN 3 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42799-0921-01 - BISOPROLOL-HCTZ 5/6.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42799-0921-30 - BISOPROLOL/HCTZ 5/6.25 MG  MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42806-0147-31 - AZITHROMYCIN 100 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42806-0149-32 - AZITHROMYCIN 200 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42806-0549-09 - DUTASTERIDE 0.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
42858-0301-25 - DILAUDID 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0016-10 - niCARDipine PREMIX 40 MG/200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0031-25 - VERAPAMIL 5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0090-25 - PROCHLORPERAZINE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0150-10 - AMIODARONE PREMIX 150 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0360-20 - AMIODARONE PREMIX 360 MG/200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43066-0997-10 - NOREPINEPHRINE 4 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43386-0090-19 - PEG 3350 AND ELECTROLYTES FOR ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43386-0405-12 - NITAZOXANIDE 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0005-03 - ROFLUMILAST 500 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0268-10 - rOPINIRole 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0336-10 - BENAZEPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0351-10 - LISINOPRIL 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0402-10 - FUROSEMIDE 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0407-10 - ClonaZEPAM 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0411-09 - QUINAPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43547-0543-25 - GLYCOPYRROLATE 0.2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0053-11 - DESMOPRESSIN ACETATE 40 MCG/10  ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0210-40 - SILVER sulfaDIAZINE 1% CREAM 400 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0210-55 - SILVER SULFADIAZINE 1% CREAM 50 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0405-16 - PHYTONADIONE 10 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0447-70 - NICOTINE 14 MG PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0447-74 - NICOTINE 14 MG/DAY PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0448-74 - NICOTINE 21 MG PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0529-11 - NEOSTIGMINE 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0666-25 - SUCCINYLCHOLINE 200 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0755-10 - LEVETIRACETAM PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43598-0848-58 - ZIPRASIDONE 20 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
43975-0322-03 - TOLTERODINE TARTRATE ER 2 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0131-10 - CEFEPIME 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0146-10 - MEROPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0150-10 - AMPICILLIN/SULBACTAM 3 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0210-10 - AMPICILLIN-SULBACTAM 1.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0235-25 - cefTAZidime 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0236-10 - cefTAZidime 2 GM INJ  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0240-10 - CEFEPIME 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0241-10 - CEFEPIME 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0246-25 - ceFOXitin 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0401-10 - MEROPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0410-24 - MAGNESIUM (PREMIX) 1 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0501-10 - levETIRAcetam PREMIX 500 mg/100 mL-NaCl 0.82% Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0502-10 - levETIRAcetam PREMIX 1000 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0611-10 - MIDAZOLAM PREMIX 100 MG/100 ML 0.9% SOD CHL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0640-10 - NOREPINEPHRINE PREMIX 4 MG/250 ML 0.9% SOD CHL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0705-10 - IMIPENEM/CILASTATIN 500 MG IV INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0707-25 - ceFAZolin 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0811-10 - ESMOLOL PREMIX 2500 MG/250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
44567-0820-10 - ERTAPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0046-35 - GENTAMICIN 0.1% OINTMENT 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"45802-0048-35 - NYSTATIN 100,000 UNITS/GM OINTMENT 15 GM",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0056-11 - gentamicin topical 0.1% Cre,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0056-35 - GENTAMICIN 0.1% CREAM (15 GM) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"45802-0059-11 - NYSTATIN CREAM 30 GM 100,000 UNITS/G (WC) [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"45802-0059-35 - NYSTATIN CREAM 100,000 UNITS/GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0060-03 - BACITRACIN 500 UNITS/GM OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0064-35 - TRIAMCINOLONE 0.1% CREAM 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0112-22 - MUPIROCIN 2% OINTMENT 22 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0143-70 - TRIPLE ANTIBIOTIC OINTMENT PACKET  0.9 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0210-01 - NITROGLYCERIN SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0221-11 - FLUTICASONE PROPIONATE 0.005% OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0221-35 - FLUTICASONE PROPIONATE 0.005% OINTMENT 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0222-11 - FLUTICASONE 0.05% CREAM 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0438-03 - HYDROCORTISONE 1% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0580-46 - SCOPALAMINE 1 MG/3 DAYS TRANSDERMAL SYSTEM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0626-26 - CETIRIZINE SYRUP 10 MG/10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0730-30 - ACETAMINOPHEN 650 MG SUPP-Adult [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0732-30 - ACETAMINOPHEN 120 MG SUPP CHILD [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0758-30 - PROMETHAZINE 12.5 MG SUPPOSITORY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0868-02 - POLYETHYLENE GLYCOL 3350 238 GM POWDER FOR SOLUTON [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0880-14 - NYSTATIN/TRIAMCINOLONE CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
45802-0900-94 - CLINDAMYCIN 1% GEL 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
46017-0011-12 - MULTIVITAMIN W/IRON LIQUID 15 ML [JHDS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
46017-0110-04 - MULTIVITAMIN W/IRON LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
46122-0557-05 - CARBAMIDE PEROXIDE OTIC 6.5% SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
46287-0024-10 - POTASSIUM PHOSPHATE 45 MMOL/15 ML INJ (WITH POTASSIUM 4.7 MEQ/ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
46287-0500-30 - SORBITOL SOLUTION 70% [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47335-0539-81 - NIACIN ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47335-0703-49 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47335-0703-52 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47335-0931-44 - VECURONIUM 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47335-0993-01 - metroNIDAZOLE PREMIX 500 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0423-47 - fentaNYL TRANSDERMAL SYSTEM 12 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0424-47 - fentaNYL TRANSDERMAL SYSTEM 25 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0426-47 - fentaNYL TRANSDERMAL SYSTEM 50 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0427-47 - fentaNYL TRANSDERMAL SYSTEM 75 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0428-47 - fentaNYL 100 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0729-02 - VANCOMYCIN 125 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
47781-0730-02 - VANCOMYCIN 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
48433-0202-30 - MINERAL OIL 30 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49230-0643-31 - CALCIUM ACETATE 667 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49281-0215-15 - TETANUS AND DIPHTHERIA TOXOIDS ADSORBED 0.5 ML INJ (7 YRS AND OLDER) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49281-0400-20 - TETANUS/DIPHTHERIA/ACELLULAR PERTUSSIS VACCINE 0.5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49281-0752-21 - TUBERCULIN PPD INJ 5 UNITS/0.1 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49348-0143-70 - POLYETHYLENE GLYCOL POWDER 238 GM BOTTLE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49348-0303-39 - ALUMINUM-MAGNESIUM-SIMETHICONE 1200-1200-120 MG PER 15 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49348-0991-36 - PHENASEPTIC 1.4% TOPICAL ANESTHETIC/ANALGESIC SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49884-0171-11 - COLCHICINE 0.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49884-0465-65 - CHOLESTYRAMINE POWDER 4 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
49884-0724-01 - HYDROXYUREA 500 MG CAP *CHEMO DRUGS-USE GLOVES* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50111-0560-01 - traZODone 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50111-0918-01 - TORSEMIDE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50190-0142-63 - RT SODIUM CHLORIDE 3% INHALATION SOLN 4 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50228-0109-01 - CARISOPRODOL 350 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50228-0146-01 - HYDROCHLOROTHIAZIDE 12.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50242-0041-64 - CATHFLO ACTIVASE 2 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50242-0085-27 - ALTEPLASE 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50242-0120-01 - TENECTEPLASE 50 MG KIT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50242-0120-47 - TENECTEPLASE 50 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50242-0137-01 - TOCILIZUMAB 400 MG20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0088-15 - ARIPiprazole 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0089-15 - ARIPiprazole 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0110-15 - BENAZEPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0127-15 - BISOPROLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0131-15 - BUMETANIDE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0177-15 - CILOSTAZOL 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0279-15 - DOXYCYCLINE HYCLATE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0330-15 - FLUDROCORTISONE 0.1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0360-15 - GLIMEPIRIDE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0398-50 - hydrOXYzine PAMOATE 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0430-15 - INDOMETHACIN 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0447-15 - ISOSORBIDE DINITRATE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0470-13 - levETIRAcetam 500 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0525-15 - MELOXICAM 7.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0534-15 - metroNIDAZOLE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0535-15 - metroNIDAZOLE 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0540-15 - METOPROLOL SUCC ER 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0583-15 - NIACIN  ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0585-15 - PANTOPRAZOLE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0625-15 - NITROFURANTOIN 100 MG CAP [JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0630-15 - QUEtiapine 25 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0632-15 - QUEtiapine 100 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0639-15 - PANTOPRAZOLE DR 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0686-15 - PRIMIDONE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0732-12 - SUCRALFATE 1 GM/10 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0740-15 - TAMSULOSIN 0.4 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0756-15 - TORSEMIDE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0757-15 - TORSEMIDE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0774-15 - traMADol-APAP 37.5/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0776-15 - traZODone 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0812-12 - ZIPRASIDONE 40 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0813-12 - ZIPRASIDONE 60 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0851-15 - VITAMIN B-1 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0855-15 - CYANOCOBALAMIN 1000 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50268-0858-11 - PYRIDOXINE 50 MG Tab [JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0063-07 - GuaiFENesin 100 MG/5 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0079-16 - ACETAMINOPHEN/CODEINE 120/12 MG PER 5 ML OS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0087-12 - GUAIFENESIN/CODEINE 200/20 MG PER 10 ML ORAL SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0771-11 - DOCUSATE 100 MG/10 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0775-04 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0775-17 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0778-16 - FERROUS SULFATE 220 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0804-16 - PROMETHAZINE-CODEINE 10-6.25 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50383-0810-16 - ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50458-0578-30 - RIVAROXABAN 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50458-0579-30 - RIVAROXABAN 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50458-0580-30 - RIVAROXABAN 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50484-0010-30 - COLLAGENASE OINT 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50580-0457-11 - ACETAMINOPHEN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50632-0010-01 - RABIES VIRUS VACCINE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50633-0110-12 - SNAKEBITE ANTIVENIN - CROFAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50633-0120-11 - DIGOXIN IMMUNE FAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50742-0175-01 - ISOSORBIDE MONO ER 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50742-0250-90 - dilTIAZem ER 240 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50742-0260-01 - NIFEdipine ER 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
50742-0505-10 - TRANSDERM SCOPALAMINE 1 MG PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0072-20 - FUROSEMIDE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0073-20 - FUROSEMIDE 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0075-20 - hydrALAZINE HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0086-20 - MIRTAZAPINE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0170-20 - METOPROLOL SUCC ER 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0206-20 - ALLOPURINOL 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0246-20 - LORATADINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0255-20 - METOPROLOL TARTRATE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0284-20 - diAZEpam 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0285-20 - diAZEpam 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0375-20 - chlordiazePOXIDE 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0437-20 - DOXEPIN 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0443-20 - LEVOTHYROXINE 125 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0565-20 - THIORIDAZINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0566-20 - THIORIDAZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0684-20 - ATENOLOL 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0734-20 - HALOPERIDOL 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0753-20 - SUCRALFATE 1 GM TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0759-20 - ATENOLOL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0801-20 - METOPROLOL TARTRATE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0821-20 - levETIRAcetam 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0888-20 - METOCLOPRAMIDE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0905-20 - PHENYTOIN SOD EXTENDED 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0923-20 - CARBIDOPA/LEVODOPA ER 50/200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0930-20 - CARVEDILOL 6.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51079-0986-20 - busPIRone 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-1282-02 - TRIAMCINOLONE 0.1% CREAM 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-1304-06 - TERCONAZOLE VAG CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-2102-08 - CETIRIZINE 10 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-2116-02 - ACETAMINOPHEN 325 MG SUPP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-2120-02 - TRIPLE ANTIBIOTIC OINT 28 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-3020-09 - LIDOCAINE 5% OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-4041-01 - carBAMazepine 100 MG CHEW TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-4070-08 - CETIRIZINE 10 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51672-4111-01 - PHENYTOIN SOD EXTENDED 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51754-0108-03 - TRANEXAMIC ACID PREMIX 1000 MG/100 ML NACL 07% [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51754-1240-03 - NEOSTIGMINE 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51754-2001-04 - POT ACETATE 40 meq/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51754-4200-04 - ePHEDrine 50 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51754-5012-04 - SODIUM BICARBONATE 4.2% 5 MEQ/10 ML INJ (INFANT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51801-0001-30 - POTASSIUM BICARBONATE 25 MEQ TAB (EFFERVESCNET) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51801-0001-40 - POTASSIUM BICARBONATE 25 MEQ TAB (EFFERVESCENT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51862-0180-15 - PRAMOXINE 1% FOAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51862-0194-60 - CLARITHROMYCIN ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51862-0455-04 - cloNIDine 0.3 MG/DAY PATCH (BI 33) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51991-0144-17 - METHYLERGONOVINE 0.2 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51991-0526-01 - TERBINAFINE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
51991-0651-16 - levETIRAcetam 500 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52244-0200-10 - THEOPHYLLINE ER 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52268-0100-01 - PEG 3350 AND ELECTROLTES FOR ORAL SOLUTION 4000 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52565-0008-14 - LIDOCAINE 5% OINTMENT 35.44 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52565-0085-15 - GENTAMICIN SULFATE 0.1% CREAM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52817-0210-10 - CYPROHEPTADINE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52817-0270-30 - BISOPROLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52817-0291-10 - OXAZEPAM 15 MG CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52817-0325-10 - MIDODRINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
52817-0330-10 - CYCLOBENZAPRINE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
53329-0014-11 - FLEET ENEMA SALINE ADULT 133 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
53746-0361-01 - FOLIC ACID 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
53746-0544-01 - PRIMIDONE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
53746-0545-01 - PRIMIDONE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54643-5649-01 - MULTI-VIT ADULT VITAMINS INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54838-0001-80 - FERROUS SULFATE 220 MG/5 ML ELIXIR [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54838-0502-80 - hydrOXYzine 10 MG/5 ML SYRUP (5 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54838-0506-15 - HYOSCYAMINE SULFATE 0.125 MG/1 ML ORAL DROPS 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54838-0511-80 - hyoscyamine 0.125 mg/5 mL Liq,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54859-0808-08 - SENNOSIDES 8.8 MG/5 ML SYRUP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54859-0810-16 - FERROUS SULFATE 220 MG/5 ML ELIXIR [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
54932-0501-81 - PHENobarbital ELIXIR 20 MG/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0114-20 - AMPICILLIN 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0119-30 - PIPERACILLIN-TAZOBACTAM 2.25 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0120-30 - PIPERACILLIN-TAZOBACTAM 3.375 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0122-15 - NAFCILLIN 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0123-15 - NAFCILLIN 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0123-16 - NAFCILLIN 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0154-10 - ACYCLOVIR 500 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0155-20 - ACYCLOVIR 1000 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0155-21 - ACYCLOVIR 1000 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0159-74 - LIDOCAINE 1% (MPF) 50 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0162-05 - LIDOCAINE 1% (MPF) 50 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0165-05 - LIDOCAINE 2% 100 MG/5 ML INJ (MPF) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0170-30 - BUPivacaine 0.5% preservative-free Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0173-01 - SUMAtriptan 6 mg/0.5 mL INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0173-05 - SUMAtriptan INJ 6 MG/0.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0174-10 - AZITHROMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0188-10 - TRANEXAMIC ACID 1000 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0194-10 - ESMOLOL 100 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0202-10 - PANTOPRAZOLE 40 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0221-10 - ETOMIDATE 20 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0226-10 - ROCURONIUM 100 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0235-10 - VECURONIUM 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0242-51 - LINEZOLID PREMIX 600 MG/D5% 300 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0246-47 - levETIRAcetam PREMIX 500 mg/100 mL-NaCl 0.82% Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0247-47 - LEVETIRACETAM PREMIX 1000 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0250-50 - BUPIVACAINE 0.5% INJ - 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0282-09 - ERTAPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0300-25 - PHENYLEPHRINE 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0308-01 - OLANZapine 10 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
55150-0345-10 - NALOXONE 2 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0014-01 - TAMSULOSIN 0.4 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0017-60 - DULoxetine DR 20 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0018-90 - DULoxetine 30 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0040-01 - PENICILLIN V K 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0042-90 - valACYclovir 500 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0172-01 - VENLAFAXINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0182-90 - PRAMIPEXOLE 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57237-0219-30 - PIOGLITAZONE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57664-0377-08 - traMADol 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57664-0503-89 - tiZANidine 4 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57664-0648-88 - CHLORTHALIDONE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0181-05 - ARTIFICIAL TEARS 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0184-05 - ARTIFICIAL TEARS 15 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0454-01 - SENNOSIDES 8.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0752-01 - VITAMIN E 400 IU SOFTGEL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0791-01 - SIMETHICONE 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57896-0921-01 - ASPIRIN EC 325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
57970-0100-01 - DALBAVANCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58160-0821-52 - VAC - HEPATITIS B INJ 20 MCG/ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58160-0887-52 - INFLUENZA QUADRIVALENT VACCINE 0.5 ML INJ (6 MONTHS AND OLDER) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58160-0890-52 - INFLUENZA QUADRIVALENT VACCINE 0.5 ML INJ (6 MONTHS OF AGE & OLDER) 2022/2023 [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58160-0909-52 - INFLUENZA QUADRIVALENT VACCINE 0.5 ML INJ (6 MONTHS AND OLDER) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58160-0964-12 - RABIES VIRUS VACCINE 2.5 IU INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58602-0702-84 - LORATADINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58657-0500-16 - guaiFENesin/CODEINE 100-10 MG PER 5 ML OS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58657-0528-16 - diphenhydrAMINE 25 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58980-0409-12 - GLYCERIN PEDIATRIC 1 GM SUPPOSITORY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
58980-0415-12 - BISACODYL 10 MG SUPPOSITORY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59016-0420-16 - MAGNESIUM LACTATE 84 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59338-0775-01 - FERUMOXYTOL 510 MG/17 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59651-0026-75 - AMOXICILLIN/CLAVULANATE 250/62.5 MG/5 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"59676-0310-01 - EPOETIN ALFA 10,000 UNITS/ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59676-0580-15 - COVID-19 VACCINE (JOHNSON & JOHNSON) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59730-4203-01 - HEPATITIS B IMMUNE GLOBULIN 1560 units/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59746-0113-06 - PROCHLORPERAZINE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59746-0383-06 - TERAZOSIN 1 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59746-0385-06 - TERAZOSIN 5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-0075-01 - HYDROCORTISONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-1061-01 - DIPHENOXYLATE/ATROPINE 2.5/0.025 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-3120-01 - AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-3720-01 - ALPRAZolam 0.5 mg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-3721-01 - ALPRAZolam 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-5029-01 - FLUCONAZOLE 10 MG/1 ML ORAL SUSPENSION 35 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
59762-5310-01 - PRAZOSIN HCL 1 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60219-1749-03 - ATROPINE 1% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60258-0006-01 - PHOSPHORUS-SODIUM-POTASSIUM 250-160-280 MG PER PACKET,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60432-0065-47 - AMOXICILLIN/CLAV POT 250 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60432-0065-75 - AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60432-0131-08 - PHENYTOIN SUSP 125 MG/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60432-0608-16 - PROMETHAZINE 6.25 MG/5 ML SYRUP PLAIN,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0080-00 - SOTALOL 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0083-02 - PARoxetine 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0141-00 - glipiZIDE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0157-01 - buPROPion 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0158-01 - buPROPion 75 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0593-04 - TRAVOPROST Z 0.004% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-0829-01 - FLUTICASONE PROPIONATE 50 MCG NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-1316-03 - PARoxetine ER 12.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-2527-03 - MODAFINIL 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-2656-01 - TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5/25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-3111-00 - OLANZapine 5 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-3114-00 - OLANZAPINE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6130-00 - ONDANSETRON 4 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6130-05 - ONDANSETRON 4 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6144-00 - CEFEPIME 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6145-00 - CEFEPIME 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6147-00 - CEFEPIME 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6148-00 - cefTRIAXone 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6148-04 - cefTRIAXone 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6149-00 - cefTRIAXone 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6149-04 - cefTRIAXone 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6151-01 - cefTRIAXone 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6152-04 - cefTRIAXone 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6156-04 - PIPERACILLIN/TAZOBACTAM 2.25 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6157-00 - PIPERACILLIN/TAZOBACTAM 3.375 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6157-04 - PIPERACILLIN-TAZOBACTAM 3.375 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6159-04 - PIPERACILLIN-TAZOBACTAM 4.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6196-00 - ERTAPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6196-04 - ERTAPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-6236-00 - DEFEROXAMINE 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-7080-02 - fentaNYL TRANSDERMAL SYSTEM 12 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-7082-02 - fentaNYL 50 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60505-7083-02 - fentaNYL 75 MCG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0113-01 - cloNIDine HCL 0.1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0122-01 - predniSONE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0143-01 - metFORMIN 850 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0145-01 - predniSONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0161-01 - HALOPERIDOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0163-01 - CEPHALEXIN 500 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0178-01 - PRAVASTATIN 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0195-01 - diltiaZEM ER 120 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0206-01 - diltiaZEM ER 180 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0224-01 - GEMFIBROZIL 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0242-01 - SERTRALINE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0282-65 - AZITHROMYCIN 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0292-01 - DONEPEZIL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0312-01 - buPROPion XL 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0315-21 - CAPTOPRIL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0345-01 - CALCITRIOL 0.25 MCG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0368-01 - BENZTROPINE MESYLATE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0370-01 - methIMAzole 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0380-01 - DICYCLOMINE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0391-01 - PIOGLITAZONE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0394-83 - RT IPRATROPIUM 0.5 MG/2.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0405-83 - RT IPRATROPIUM-ALBUTEROL 0.5 MG/3 MG PER 3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0428-65 - FINASTERIDE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0432-01 - traZODone 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0433-01 - AMITRIPTYLINE HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0436-01 - CELECOXIB 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0443-01 - traZODone 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0453-01 - LEVOTHYROXINE 25 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0457-01 - IBUPROFEN 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0464-01 - LEVOTHYROXINE 50 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0468-01 - IBUPROFEN 800 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0475-01 - LEVOTHYROXINE 75 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0483-01 - NITROFURANTOIN 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0484-01 - PREGABALIN 50 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0486-01 - LEVOTHYROXINE 88 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0495-01 - PREGABALIN 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0497-01 - LEVOTHYROXINE 100 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0508-01 - LEVOTHYROXINE 112 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0519-01 - LEVOTHYROXINE 125 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0530-01 - LEVOTHYROXINE 150 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0540-01 - DIGOXIN 0.125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0541-01 - LEVOTHYROXINE 175 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0544-01 - ClonaZEPAM 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0550-01 - metroNIDAZOLE 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0551-01 - DIGOXIN 0.25 MG TAB  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0555-01 - ClonaZEPAM 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0558-01 - CYCLOBENZAPRINE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0559-01 - METHOCARBAMOL 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0570-01 - PRAMIPEXOLE 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0580-01 - GABAPENTIN 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0585-01 - PANTOPRAZOLE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0586-01 - rifAMPin 300 mg Cap [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0591-01 - GABAPENTIN 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0593-01 - HYDROCHLOROTHIAZIDE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0598-01 - PROPRANOLOL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0622-01 - SENNOSIDES/DOCUSATE 8.6/50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0629-21 - FENOFIBRATE 145 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0631-01 - METOCLOPRAMIDE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0634-01 - valsartan 160 mg Tab,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0640-01 - metFORMIN ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0661-01 - CARBIDOPA/ LEVODOPA 25/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0671-67 - PHENobarbital 20 MG/5 ML ELIXIR [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0680-01 - methIMAzole 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0681-01 - FOLIC ACID 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0695-01 - sucralfate 1 gm tab 1 g Tab,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0711-01 - OXcarbazepine 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0722-01 - OXcarbazepine 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60687-0727-21 - COLCHICINE 0.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60758-0119-05 - prednisoLONE ACET 1% OPTH SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60758-0188-05 - GENTAMICIN 0.3% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60758-0801-05 - TIMOLOL 0.5% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60758-0908-10 - POLYMIXIN/TRIMETHOPRIM OPTH DROPS [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60793-0600-10 - PENICILLIN G BENZ/PEN G PROCAINE 1.2 MU (IM) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60793-0701-10 - PENICILLIN G BENZ 1.2 MILLION UNIT/2 ML (IM) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
60977-0141-01 - PRALIDOXIME CHL 1  GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61269-0105-56 - BACITRACIN 500 UNITS/GM OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0144-05 - BRIMONIDINE 0.15% OPTH SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0227-05 - TIMOLOL 0.5% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0547-01 - LATANOPROST OPTH DROPS 0.005% [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0633-05 - GENTAMICIN 0.3% OPTH SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0641-75 - NEOMYCIN/POLYMYXIN B/HYDROCORTISONE OPTH SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0643-05 - TOBRAMYCIN 0.3% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0646-10 - hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Sol [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61314-0656-05 - CIPROFLOXACIN 0.3% OPTH SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61570-0131-40 - SILVER SULFADIAZINE 1% CREAM 400 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61958-0701-01 - EMTRICITABINE/TENOFOVIR 200/300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61958-2901-02 - REMDESIVIR 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61990-0211-03 - PHENYLEPHRINE 10 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
61990-0611-02 - TRANEXAMIC ACID 1000 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62135-0712-42 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62332-0034-31 - rOPINIRole 3 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62332-0079-90 - VALSARTAN/HYDROCHLOROTHIAZIDE 80/12.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62332-0121-90 - PREGABALIN 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62332-0582-04 - LIDOCAINE-PRILOCAINE 2.5-2.5% CREAM [JDHS,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62332-0600-25 - KETOROLAC 30 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62559-0190-16 - METOCLOPRAMIDE 10 MG/10 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62559-0431-30 - HYDROCORTISONE 2.5% CREAM 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62559-0511-01 - INDAPAMIDE 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62584-0265-01 - METOPROLOL TARTRATE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62584-0266-01 - METOPROLOL TARTRATE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62584-0733-01 - hydrALAZINE HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62584-0897-01 - FOLIC ACID 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62584-0984-01 - WARFARIN 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62756-0059-40 - EPOPROSTENOL *INH* 1.5 MG/NS 50 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
62756-0183-88 - OXcarbazepine 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63304-0017-60 - RANOLAZINE ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0010-02 - GENTAMICIN 80 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0013-01 - VITAMIN B-1 200 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0013-02 - VITAMIN B-1 200 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0044-01 - CYANOCOBALAMIN 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0064-11 - MAGNESIUM SULFATE 5 GM/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0086-05 - POTASSIUM PHOSPHATES 45 Mmol/15 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0093-30 - SODIUM CHLORIDE 23.4% 120 MEQ/30 ML INJ (CONCENTRATE MUST BE DILUTED FOR IV USE) [JD,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0106-01 - MAGNESIUM (PREMIX) 4 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0130-13 - DOXYCYCLINE 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0162-01 - KETOROLAC 30 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0162-02 - KETOROLAC 60 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0170-05 - SODIUM PHOSPHATE 15 mMol/5 ml [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0173-02 - GENTAMICIN 20 MG/2 ML INJ (PEDIATRIC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0184-10 - FOLIC ACID 50 MG/10 ML INJ (1 MG = 0.2 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0185-10 - STERILE WATER FOR INJECTION 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0186-02 - SODIUM CHLORIDE FOR INJ 20 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0186-10 - SOD CHL 0.9% FOR INJ 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0186-20 - SODIUM CHLORIDE 0.9% FOR INJECTION 20 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0229-35 - PROTAMINE 250 MG/25 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0255-03 - methylPREDNISolone 40 mg Pow,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0258-03 - methylPREDNISolone 125 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"63323-0262-06 - HEPARIN 5,000 UNITS/ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0262-26 - HEPARIN 5000 UNITS/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0269-29 - PROPOFOL 200 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0269-37 - PROPOFOL 200 MG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0269-65 - PROPOFOL PREMIX 1000 MG/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0284-20 - VANCOMYCIN 1000 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0341-01 - ceFOXitin 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0349-25 - IMIPENEM-CILASTATIN 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0349-93 - IMIPENEM/CILASTATIN 250 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0360-19 - CALCIUM GLUCONATE 10% 1 GM/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0376-01 - OCTREOTIDE 100 MCG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0377-01 - OCTREOTIDE 500 MCG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0401-20 - AZTREONAM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0401-26 - AZTREONAM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0402-20 - AZTREONAM 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0402-30 - AZTREONAM 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0424-05 - FLUMAZENIL 0.5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0451-01 - MORPHINE 10 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0452-01 - MORPHINE 2 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0454-01 - MORPHINE 4 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0466-37 - BUPIVACAINE 0.5% PRESERVATIVE-FREE 150 MG/30 ML INJ (SDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0474-01 - HALOPERIDOL 5 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0482-27 - LIDOCAINE WITH EPI 1% 20 ML MDV [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0492-27 - LIDOCAINE 1% (MPF) INJ 2 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0492-36 - LIDOCAINE 1% (MPF) 50 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0492-43 - LIDOCAINE 1% (MPF) INJ 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0492-57 - LIDOCAINE 1% (MPF) 50 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0495-04 - LIDOCAINE 2% (MPF) VIAL 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0495-07 - LIDOCAINE 2% 100 MG/5 ML INJ (MPF) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0508-31 - MEROPENEM 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"63323-0517-74 - HEPARIN PREMIX 25,000 UNITS/250 ML 0.45% SODIUM CHLORIDE [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"63323-0523-74 - HEPARIN PREMIX 25,000 UNITS IN DEXTROSE 5% 250 ML [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0531-01 - ENOXAPARIN 80 MG/0.8 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0531-90 - ENOXAPARIN 80 MG/0.8 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0531-98 - ENOXAPARIN 80 MG/0.8 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0533-93 - ENOXAPARIN 30 MG/0.3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0535-98 - ENOXAPARIN 40 MG/0.4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0537-84 - ENOXAPARIN 150 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0564-97 - ENOXAPARIN 40 MG/0.4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0597-10 - DEFEROXAMINE 500 MG *IM* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0605-94 - ENOXAPARIN 100 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0607-88 - ENOXAPARIN 60 MG/0.6ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0607-98 - ENOXAPARIN 60 MG/0.6 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0614-01 - hydrALAZINE 20 MG/ML Inj [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0616-01 - AMIODARONE 150 MG/3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0616-03 - AMIODARONE 150 MG/3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0660-05 - METOPROLOL 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0664-01 - diphenhydrAMINE 50 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0665-01 - TERBUTALINE 1 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0690-30 - ACETYLCYSTEINE 20% 6000 MG/30 ML SOLUTION **INHALATION** [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0713-13 - LINEZOLID 600 MG/300 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0739-12 - FAMOTIDINE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0781-10 - VECURONIUM 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0806-02 - fentaNYL 100 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0806-05 - fentaNYL 250 MCG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0806-20 - fentaNYL 1000 MCG/20 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0940-04 - NOREPINEPHRINE 4 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63323-0963-21 - Acetylcysteine 6000 MG/30 ML **INJECTION** [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63402-0302-30 - LURASIDONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63402-0304-30 - LURASIDONE 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63629-1079-02 - POTASSIUM CHLORIDE ER 10 MEQ CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63629-2095-01 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63629-8847-01 - HYDROCORTISONE 2.5% CREAM 30 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63736-0730-05 - OXYMETAZOLINE 0.05% NASAL SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63736-1200-01 - BEDDING LICE SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63736-1200-02 - PERMETHRIN 1% LOTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0016-10 - diltiaZEM ER 240 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0051-10 - AMIODARONE HCL 200 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0086-10 - VALPROIC ACID 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0098-10 - MIRTAZAPINE 15 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0108-10 - CARBIDOPA/ LEVODOPA 25/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0212-02 - ASPIRIN EC 81 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0327-10 - hydrALAZINE HCL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0410-10 - ALLOPURINOL 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0479-10 - BACLOFEN 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0483-10 - hydrOXYzine 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0486-10 - hydrOXYzine 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0526-10 - ZOLPIDEM 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0544-10 - SPIRONOLACTONE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0549-73 - MEGESTROL ACETATE 400 MG/10 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0564-10 - PANTOPRAZOLE DR 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0567-10 - TAMSULOSIN 0.4 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0571-10 - SIMVASTATIN 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0572-10 - SIMVASTATIN 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0573-10 - SIMVASTATIN 40 MG TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0645-10 - FAMOTIDINE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0673-10 - LOSARTAN POTASSIUM 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0686-10 - LOSARTAN POTASSIUM 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0795-10 - levETIRAcetam 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0796-10 - ALLOPURINOL 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0903-10 - GABAPENTIN 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0904-10 - GABAPENTIN 400 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"63739-0953-25 - HEPARIN 5,000 UNITS/ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0963-10 - PARoxetine 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63739-0973-10 - POTASSIUM CHL ER 20 MEQ TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63824-0056-32 - guaiFENesin/DEXTROMETHORPHAN 30/600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63824-0056-34 - guaiFENesin/DEXTROMETHORPHAN 30/600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63824-0056-40 - guaiFENesin/DEXTROMETHORPHAN 600/30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63824-0744-16 - benzocaine-dextromethorphan 7.5 mg-5 mg Loz [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
63833-0386-02 - PROTHROMBIN COMPLEX CONC HUMAN 500 UNIT KIT INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64253-0111-30 - SODIUM CHLORIDE 0.9% FLUSH 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64253-0202-30 - SODIUM CHLORIDE 0.9% FLUSH 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64253-0333-35 - HEPARIN LOCK FLUSH 500 UNITS/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64253-0900-91 - CALCIUM CHLORIDE 10% 1 GM/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64380-0799-01 - OSELTAMIVIR 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64380-0834-06 - acetaZOLAMIDE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64679-0012-01 - PIPERACILLIN /TAZOBACTAM 4.5 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64679-0925-02 - ENALAPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64980-0339-01 - MAGNESIUM OXIDE 400 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64980-0511-10 - CLINDAMYCIN PALMITATE 75 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64980-0514-05 - TIMOLOL 0.5% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
64980-0526-60 - NITAZOXANIDE 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0465-10 - IBUPROFEN 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0553-10 - METAXALONE 800 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0681-10 - PHENAZOPYRIDINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0710-03 - COLCHICINE 0.6 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0755-10 - DIVALPROEX SOD ER 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0757-10 - DIVALPROEX SOD ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0879-03 - LURASIDONE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0880-03 - LURASIDONE 40 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0896-03 - ARIPiprazole 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65162-0897-09 - ARIPiprazole 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65219-0433-15 - PANTOPRAZOLE 40 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65219-0445-10 - ETOMIDATE 20 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65757-0403-03 - ARIPiprazole 882 MG/3.2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65757-0404-03 - ARIPiprazole 1064 MG/3.9 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65757-0500-03 - ARIPiprazole 675 MG/2.4 ML INJ STARTER DOSE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0012-01 - SERTRALINE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0036-60 - LAMIVUDINE/ZIDOVUDINE 150/300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0116-01 - BENAZEPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0146-36 - SUMAtriptan 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0168-01 - ATENOLOL 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0185-01 - CLINDAMYCIN 150 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0227-01 - LamoTRIgine 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0468-90 - LOSARTAN POT/HCT 50/12.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0475-01 - RAMIPRIL 2.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0477-01 - RAMIPRIL 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0496-47 - SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/10 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0502-20 - AMOXICILLIN-CLAVULANATE 500-125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0503-01 - AMOXICILLIN/CLAV POT 875/125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0559-90 - PANTOPRAZOLE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0594-01 - DIVALPROEX SOD ER 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0595-01 - DIVALPROEX SOD ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0641-63 - AZITHROMYCIN 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0677-01 - ALPRAZolam 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0699-20 - CEFUROXIME 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
65862-0707-55 - AMOXICILLIN 250 MG/5 ML ORAL SUSP 150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66553-0001-01 - ASPIRIN 325 MG TAB [JDHS],25680,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66689-0023-50 - HYDROcodone/APAP 7.5 MG/325 MG PER 15 ML ORAL SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"66689-0037-50 - NYSTATIN 500,000 UNITS/5 ML ORAL SUSPENSION [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66689-0038-50 - LACTULOSE 20 GM/30 ML ORAL SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66689-0053-99 - MILK OF MAGNESIA ORAL SUSP 2400MG/30 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66689-0203-04 - CHARCOAL/SORBITOL SUSP 25 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66689-0775-08 - PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66794-0219-43 - LINEZOLID PREMIX 600 MG/300 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66794-0230-42 - DEXMEDETOMIDINE 200 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66794-0233-42 - DEXMEDETOMIDINE 200 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66993-0141-30 - ALISKIREN 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66993-0586-97 - FLUTICASONE-SALMETEROL 500-50 MCG INHALATION POWDER [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
66993-0730-80 - dexAMETHasone 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"67157-0101-50 - ASCORBID ACID 25,000 MG/50 ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0001-10 - KETAMINE 500 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0108-10 - KETAMINE 1000 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0153-03 - AMIODARONE 150 MG/3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0292-02 - NALOXONE 0.4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0339-50 - VANCOMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0339-50 - VANCOMYCIN 500 MG **PO** VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0340-01 - VANCOMYCIN 1000 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0423-12 - dexAMETHasone 4 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0426-12 - HALOPERIDOL 5 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0437-10 - DOXYCYCLINE 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0473-22 - TOBRAMYCIN 80 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0640-99 - PROCHLORPERAZINE 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0645-02 - NALOXONE 0.4 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0790-05 - LEVETIRACETAM 500 mg/5 ml inj [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0853-50 - acetaZOLAMIDE 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0855-02 - ADENOSINE 6 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67457-0887-99 - medroxyPROGESTERone 150 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67546-0212-21 - NITAZOXANIDE 100 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67850-0031-10 - NAFCILLIN 1 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0124-05 - SILVER sulfADIAZINE 1% CREAM 50 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0124-20 - SILVER SULFADIAZINE 1% CREAM  20 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0124-40 - SILVER sulfADIAZINE 1% CREAM 400 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0198-90 - amLODIPine 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0215-20 - CEFUROXIME 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0251-15 - TRIAMCINOLONE 0.1% CREAM 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0251-30 - TRIAMCINOLONE 0.1% CREAM 30 GM (WC) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0263-60 - DULoxetine 20 mg Cap [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0298-60 - CHOLESTYRAMINE 4 G/8.780  G POWDER RECON [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0392-30 - NEBIVOLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0419-20 - LINEZOLID 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
67877-0490-90 - EZETIMIBE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0027-01 - WARFARIN 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0045-01 - PARoxetine 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0202-01 - PRIMIDONE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0203-01 - PRIMIDONE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0214-01 - BENZONATATE 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0253-01 - hydrOXYzine 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0270-01 - risperiDONE 0.25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0284-01 - HYDROXYUREA 500 MG CAP *CHEMO DRUGS-USE GLOVES* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0313-01 - DIVALPROEX SOD 125 MG CAP (SPRINKLE) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0318-01 - LamoTRIgine 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0319-01 - LamoTRIGINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0326-01 - GLIMEPIRIDE 2 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0327-01 - GLIMEPIRIDE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0343-01 - TOPIRAMATE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0343-21 - TOPIRAMATE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0346-01 - LOSARTAN POTASSIUM 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0388-01 - BENZTROPINE MESYLATE 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0491-01 - MECLIZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0512-01 - SIMVASTATIN 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0536-01 - CLOPIDOGREL 75 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0539-01 - TORSEMIDE 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0591-01 - ISOSORBIDE MONO ER 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0605-01 - FLUoxetine 20 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0654-01 - SOTALOL 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0676-01 - METOCLOPRAMIDE 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0683-01 - DULoxetine 30 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0698-01 - VENLAFAXINE ER 37.5 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0709-01 - VENLAFAXINE ER 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0710-01 - OXYCODONE/APAP 10/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0728-01 - FLUCONAZOLE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0738-01 - METHADONE TAB 10 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0753-25 - CYCLOBENZAPRINE 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0776-01 - DIVALPROEX SOD DR 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0808-01 - traMADol 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0825-01 - traMADol-APAP 37.5/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0845-01 - OXcarbazepine 150 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0847-01 - hydrOXYzine PAMOATE 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0853-01 - OXcarbazepine 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0859-01 - levETIRAcetam 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0895-01 - HYDROcodone-ACETAMINOPHEN 5-325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0895-09 - HYDROcodone/APAP 5/325 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68084-0964-25 - PROPYLTHIOURACIL 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0024-62 - diphenhydrAMINE 25 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0030-59 - ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0037-58 - IBUPROFEN 100 MG/5 ML CHILDREN'S ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0043-62 - SUCRALFATE 1 GM/10 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0063-62 - MEGESTROL 400 MG/10 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0101-20 - PHENTOLAMINE MESYLATE 5 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0112-61 - FOLIC ACID 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0231-61 - ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0231-62 - ACETAMINOPHEN 160 MG/5 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0250-62 - MEGESTROL 400 MG/10 ML ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0494-62 - IBUPROFEN 100 MG/5 ML CHILDREN'S ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0600-62 - IBUPROFEN 100 MG/5 ML CHILDREN'S ORAL SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68094-0764-59 - MIDAZOLAM SYRUP 10 MG/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0167-13 - VANCOMYCIN 250 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0180-08 - CEFADROXIL 500 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0181-02 - CEFADROXIL 250 MG/5 ML SUSPENSION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0441-01 - CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0512-01 - LISINOPRIL 2.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0557-09 - QUINAPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0678-01 - OSELTAMIVIR PHOSPHATE 6 MG/1 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0711-60 - CEFDINIR 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0798-01 - POTASSIUM CHLORIDE ER 8 MEQ CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0981-03 - LISINOPRIL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68180-0984-30 - RT BUDESONIDE 0.5 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"68308-0152-15 - NYSTATIN 100,000 UNITS/GM TOPICAL POWDER 15 GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0006-01 - LamoTRIgine 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0255-01 - OXYBUTYNIN CHL ER 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0310-30 - NITROGLYCERIN 0.4 MG/HR PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0318-18 - MINOCYCLINE 100 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"68382-0370-01 - NYSTATIN 100,000 UNITS/GM TOPICAL POWDER 15 GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0546-06 - MEMANTINE ER 7 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68382-0910-10 - DOXYCYCLINE 100 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0138-01 - OXcarbazepine 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0157-13 - ONDANSETRON ODT 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0180-22 - MUPIROCIN 2% OINTMENT [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0260-01 - VERAPAMIL ER 240 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0298-17 - CLOTRIMAZOLE-BETAMETHASONE DIPROPIONATE 1%-0.05% CREAM 15 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"68462-0314-17 - NYSTATIN-TRIAMCINOLONE 100,000 UNITS-1 MG PER 1 GM CREAM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0405-60 - ASA/DIPYRIDAMOLE 25/200 mg CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0406-01 - INDOMETHACIN 25 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0639-45 - NITROGLYCERIN 0.4 MG SL TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68462-0721-01 - THEOPHYLLINE ER 300 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68516-5216-08 - ALBUMIN SOLN 25 GM/100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68682-0650-20 - DIAZEPAM RECTAL GEL 2.5 MG [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
68682-0920-05 - TETRACAINE 0.5% OPHTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0318-87 - RT BUDESONIDE 0.25 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0319-87 - RT BUDESONIDE 0.5 MG/2 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0524-44 - DICLOFENAC SODOIUM 1% GEL 100 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0709-96 - PHYTONADIONE NEONATAL 1 MG/0.5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0821-03 - GEMFIBROZIL 600 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0856-05 - FOSINOPRIL 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69097-0859-02 - TERBINAFINE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1056-01 - chlorproMAZINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1060-01 - chlorproMAZINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1373-02 - DEXAMETHASONE-TOBRAMYCIN 0.1%-0.3% OPTH SUSP 2.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1540-01 - URSODIOL 300 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1616-06 - OFLOXACIN 0.3% OTIC SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-1993-01 - BUTALBITAL/ASP/CAFF/COD 50/325/40/30 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69238-2122-09 - prednisoLONE 15 MG/5 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0134-01 - IMIPRAMINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0211-01 - NIFEdipine 10 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"69315-0306-15 - NYSTATIN 100,000 UNITS/GM TOPICAL POWDER 15 GM [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0308-05 - CIPROFLOXACIN 0.3% OPTH SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0904-01 - LORazepam 0.5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0905-01 - LORazepam 1 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69315-0910-01 - DIPHENOXYLATE/ATROPINE 2.5/0.025 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69339-0136-32 - diAZEpam 10 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69339-0136-34 - diAZEpam 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69452-0207-13 - CALCITRIOL 0.25 MCG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69452-0344-72 - SUMAtriptan 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69452-0389-98 - MAGNESIUM CITRATE 1.745 G/30 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69543-0125-10 - GLIMEPIRIDE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69584-0092-10 - busPIRone 10 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69584-0111-10 - CARISOPRODOL 350 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69584-0426-10 - IMIPRAMINE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69584-0852-10 - SPIRONOLACTONE 25 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69618-0033-01 - SIMETHICONE 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69680-0112-25 - CYANOCOBALAMIN 1 MG/ ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69784-0002-06 - FLUCONAZOLE 200 MG/100 ML PREMIX [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
69918-0901-10 - DESMOPRESSIN ACETATE 4 MCG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"69968-0060-09 - BACITRACIN/POLYMYXIN B 500/10,000 UNITS/G OINTMENT [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70000-0021-01 - MAGNESIUM SULFATE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70000-0526-01 - SENNOSIDES/DOCUSATE 8.6/50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70010-0063-01 - metFORMIN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70010-0147-01 - POTASSIUM CHLORIDE ER 8 MEQ CAPSULE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70010-0491-01 - metFORMIN ER 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70010-0754-01 - METHOCARBAMOL 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70069-0131-01 - TOBRAMYCIN 0.3% OPTH SOLUTION 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70069-0231-01 - BRIMONIDINE 0.2% OPTH SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70069-0421-01 - LATANOPROST 0.005% OPHTH SOLUTION 2.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70069-0783-10 - SUCCINYLCHOLINE 200 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70069-0801-25 - PHENYLEPHRINE 10 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70121-1049-02 - TRIAMCINOLONE ACET 40 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70121-1574-01 - methylPREDNISolone ACET 80 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70121-1642-05 - VASOPRESSIN 20 UNITS/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70156-0104-01 - HYOSCYAMINE 0.125 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70408-0146-34 - PROMETHAZINE 6.25 MG/5 ML SYRUP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0019-82 - AZITHROMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0020-82 - VANCOMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0020-82 - VANOCMYCIN 500 MG **PO** VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0021-82 - VANCOMYCIN 1000 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0051-06 - CILOSTAZOL 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70436-0147-81 - DICYCLOMINE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70515-0261-10 - DIGOXIN 0.5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0042-03 - VANCOMYCIN PREMIX 1000 MG/200 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0043-02 - VANCOMYCIN PREMIX 1500 MG/300 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0044-02 - VANCOMYCIN PREMIX 2000 MG/400 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0056-03 - VANCOMYCIN PREMIX 750 MG/150 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0057-02 - VANCOMYCIN PREMIX 1250 MG/250 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0058-02 - VANCOMYCIN PREMIX 1750 MG/350 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70594-0090-02 - CEFEPIME 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70677-0038-01 - MAGNESIUM SULFATE 100% SALINE LAXATIVE - SOAKING AID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70677-0054-01 - LOPERAMIDE HCL 2 MG/15 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70677-0144-01 - diphenhydrAMINE 25 MG/10 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70677-1111-01 - MAGNESIUM CITRATE 1.745 G/30 ML LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70700-0172-23 - NEOSTIGMINE 10 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70710-1110-01 - CYPROHEPTADINE 4 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70710-1457-01 - AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70710-1478-01 - FOMEPIZOLE 1.5 GM/1.5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70710-1643-07 - VERAPAMIL 5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70752-0138-12 - PROMETHAZINE 6.25 MG/5 ML SYRUP PLAIN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70752-0171-10 - PROPYLTHIOURACIL 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70756-0610-30 - OFLOXACIN 0.3% OTIC SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0100-10 - AZITHROMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0117-26 - NAFCILLIN 2 GM INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0125-66 - AZITHROMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0301-05 - dilTIAZem 25 MG/5 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0302-02 - FUROSEMIDE 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0451-10 - LEVOTHYROXINE 100 MCG*INJ* [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70860-0601-10 - MIDAZOLAM 50 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70954-0019-10 - PRAZOSIN HCL 1 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70954-0188-10 - ACYCLOVIR 200 MG/5 ML SUSP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70954-0211-10 - TRIHEXYPHENIDYL HCL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70954-0518-10 - LIDOCAINE 4% TOPICAL SOLUTION 40 MG/ML (50 ML) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71266-5100-01 - oxytocin 30 units/500 mL-NaCl 0.9% Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0016-15 - DAPTOmycin 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"71288-0403-02 - HEPARIN 5,000 UNITS/ML INJ [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0410-81 - ENOXAPARIN 30 MG/0.3 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0410-83 - ENOXAPARIN 40 MG/0.4  ML INJ,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0410-85 - ENOXAPARIN 60 MG/0.6 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0410-89 - ENOXAPARIN 100 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0411-81 - ENOXAPARIN 120 MG/0.8 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0414-03 - GLYCOPYRROLATE 0.2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0433-83 - ENOXAPARIN 40 MG/0.4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0433-92 - ENOXAPARIN 40 MG/0.4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71288-0505-03 - dexmedeTOMIDine 200 MCG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71321-0800-60 - MAGNESIUM LACTATE 84 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71321-0803-20 - CALCIUM ACETATE 667 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71399-8022-02 - ACETAMINOPHEN 500 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71740-0112-30 - POTASSIUM IODIDE 1 GM/ML ORAL SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
71839-0107-01 - DAPTOmycin 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72078-0002-04 - NOREPINEPHRINE 4 MG/4 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72140-0314-07 - Petrolatum 41% Oint 396 GM [JDHS],266087,CDM,250,RC,,HCPCS,outpatient,,,$71.00 ,$24.85 ,,$38.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.25 ,75,,,percent of total billed charges,75% of total billed charges,$53.25 ,75,,,percent of total billed charges,75% of total billed charges,$53.25 ,75,,,percent of total billed charges,75% of total billed charges,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.80 ,80,,,percent of total billed charges,80% of total billed charges,$22.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.85 ,$67.45 ,
72140-0386-08 - DRY SKIN THERAPY CREME [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72205-0042-11 - OSELTAMIVIR 30 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72205-0044-11 - OSELTAMIVIR 75 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72241-0033-22 - NEBIVOLOL 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72266-0102-01 - LABETALOL 100 MG/20 ML INJ (MDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72266-0118-25 - KETOROLAC 30 MG/ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72266-0119-25 - KETOROLAC 60 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72266-0127-05 - DICYCLOMINE HCL 20 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72266-0160-41 - ZIPRASIDONE 20 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72485-0108-25 - VERAPAMIL 5 MG/2 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72603-0115-01 - TAMSULOSIN 0.4 MG CAP  [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0722-25 - KETOROLAC 30 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0734-01 - LABETALOL 100 MG/20 ML INJ (MDV) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0740-10 - METOPROLOL 5 MG/5 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0757-10 - ROCURONIUM 100 MG/10 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0761-10 - VANCOMYCIN 500 MG INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0761-10 - VANCOMYCIN 500 MG **PO** VIAL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72888-0046-01 - PRIMIDONE 250 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72888-0106-01 - CARBIDOPA/LEVODOPA 10/100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72888-0125-26 - LIDOCAINE VISCOUS 2% ORAL SOLUTION 100 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
74300-0007-00 - ZINC OXIDE 40%  PASTE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
75826-0114-10 - PHENAZOPYRIDINE 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
75826-0138-10 - PHENobarbital 30 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
75834-0158-01 - VERAPAMIL ER 180 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
75834-0159-01 - VERAPAMIL ER 240 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76014-0005-25 - ePHEDrine 50 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76045-0004-11 - MORPHINE 2 MG/1 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76045-0009-11 - HYDROmorphone 1 mg/mL Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76125-0150-02 - RABIES IMMUNE GLOBULIN 300 IU/2 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0010-55 - RT ALBUTEROL 0.021% 0.63 MG/3 ML INHALATION SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0011-55 - RT ALBUTEROL 1.25 MG/3 ML 0.042% INHALATION SOL [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0100-01 - RT IPRATROPIUM 0.5 MG/2.5 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0200-01 - RT ALBUTEROL 2.5 MG/3 ML INHALATION SOLN (PROVENTIL) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0300-05 - RT SODIUM CHLORIDE 0.9% INHALATION SOL 5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0600-01 - RT IPRATROPIUM-ALBUTEROL 0.5 MG/3 MG PER 3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0900-01 - RT LEVALBUTEROL 1.25 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76204-0900-25 - RT LEVALBUTEROL 1.25 MG/3 ML INHALATION SOLN [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76282-0347-01 - NADOLOL 20 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76282-0663-39 - DICLOFENAC SODIUM 1% GEL 100 GM [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-1911-01 - MORPHINE PCA 30 MG/30 ML INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-1912-01 - morphine 1 mg/mL preservative-free Sol,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3302-01 - DEXTROSE 50% 25 GM/50 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3316-01 - EPINEPHrine 1 MG/10 ML INJ (SYRINGE) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3318-01 - EPINEPHrine 1 MG/10 ML INJ (SYRINGE) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3340-01 - ATROPINE 1 MG/10 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3352-01 - SODIUM BICARBONATE 8.4% 50 MEQ/50 ML INJ (ADULT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3369-01 - NALOXONE 2 MG/2 ML INJ,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-3390-01 - LIDOCAINE 2% (CARDIAC) 100 MG/5 ML SYRINGE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-6300-05 - LIDOCAINE HCL TOPICAL SOLUTION 4% KIT 160 MG/4 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
76329-9060-00 - EPINEPHrine 1 MG/ML (30 ML MDV) INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0115-10 - CALCIUM W/VITAMIN D 600 MG/400 IU TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0520-10 - MELATONIN 5 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0812-10 - SIMETHICONE 80 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0831-10 - SODIUM BICARBONATE 650 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0835-10 - SODIUM CHLORIDE 1 GM TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0934-10 - VITAMIN B-1 100 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0938-10 - CYANOCOBALAMIN 1000 MCG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0940-10 - PYRIDOXINE 50 MG TAB [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0948-10 - CHOLECALCIFEROL 400 IU TAB (10 MCG) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
77333-0983-10 - ZINC SULFATE 220 MG CAP [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
78112-0011-03 - PHENOL 1.4% ORAL ANESTHETIC SPRAY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
78670-0003-67 - DANTROLENE 20 MG POWDER INJ [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
80681-0045-00 - calcium-vitamin D 315 mg-5 mcg Tab [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"80681-1740-01 - cholecalciferol D3 50,000 IU cap [JDHS]",,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
80777-0273-98 - MODERNA COVID-19 VACCINE [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
81033-0002-30 - ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
81033-0002-50 - ACETAMINOPHEN 160 MG/5 ML ORAL SUSP,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
81033-0220-51 - POTASSIUM CHLORIDE 10% 20 MEQ/15 ML ORAL SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
81964-0204-15 - AMOXICILLIN/CLAVULANATE 250/62.5 MG/5 ML ORAL SUSPENSION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
82182-0773-05 - BRIMONIDINE 0.15% OPTH SOLUTION [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
82347-0505-05 - LIDOCAINE 5% PATCH [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
82900-2368-50 - LACTOBACILLUS TABLET [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
82900-3064-24 - HEPARIN LOCK FLUSH 500 UNITS/5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
83490-0510-35 - VORTEX HOLDING CHAMBER (ADULT) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
83490-0510-37 - VORTEX HOLDING CHAMBER (LADYBUG MASK 1-2 YEARS) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
83490-0510-39 - VORTEX HOLDING CHAMBER (FROG MASK 3+ YEARS) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
88810-5701-21 - SOD CHL 0.9% FLUSH 10 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
88840-4302-00 - PETROLEUM JELLY [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-01 - GI COCKTAIL 17.5 ML [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-01 - GI COCKTAIL 17.5 ML [JDHS] - Liquid,25163,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-01 - MAALOX-HYOSCYAMINE-LIDOCAINE VISC 2% 7.5-5-5 17.5 ML [JDHS] 17.5 mL Liquid,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-02 - BMX LIQUID [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-03-THP - THP Zofran 4mg Tablet (#3) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-04-THP - THP Tylenol with Codeine 300/30mg Tablets (#2) [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-77 - Sodium Chloride 0.45% PREMIX Diluent [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-80 - Pharmacy to Dose - Tobramycin [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-81 - Pharmacy to Dose - Gentamicin [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-82 - Morphine PREMIX PCA Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-83 - Pharmacy to Dose - Vancomycin [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-84 - DOPamine PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-85 - Pharmacy to Dose - Warfarin [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-86 - Sterile Water PREMIX Diluent [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-87 - Esmolol PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-88 - General Premix Diluent [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-89 - Propofol PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-90 - Nitroglycerin PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-91 - niCARdipine PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-92 - Lidocaine PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-93 - Labetalol PREMIX Additive [EFMC],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-94 - Empty Bag [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-95 - Dextrose 5% in Water PREMIX Diluent [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-96 - DOBUTamine PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-97 - Sodium Chloride 0.9% PREMIX Diluent [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-98 - Heparin PREMIX Additive [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99999-9999-99 - Template Non-Formulary Medication [JDHS],,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Calmoseptine Menthol / Lan Ointment,30102,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Gentamycin Sulfate Cream 0.1%,24308,CDM,637,RC,A9270,HCPCS,outpatient,,,$149.00 ,$52.15 ,,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$134.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.06 ,$141.55 ,
Silver Nitrate Stick,24652,CDM,637,RC,A9270,HCPCS,outpatient,,,$149.00 ,$52.15 ,,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.75 ,75,,,percent of total billed charges,75% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges,$47.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$134.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.06 ,$141.55 ,
TNF MED,,CDM,250,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
95992 CANALITH REPOSITIONING CHARGE,8960375,CDM,420,RC,95992,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
97010 CYROTHERAPY CHARGE,8045998,CDM,420,RC,97010,HCPCS,outpatient,,,$24.00 ,$8.40 ,,$12.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.20 ,80,,,percent of total billed charges,80% of total billed charges,$7.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.68 ,$22.80 ,
97012 MECHANICAL TRACTION CHARGE,8584372,CDM,420,RC,97012,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
97014 ELECTRICAL STIM CHARGE (PT),8805108,CDM,420,RC,97014,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
97033 IONTOPHORESIS Charge,10526262,CDM,420,RC,97033,HCPCS,outpatient,,,$109.00 ,$38.15 ,,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.75 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges,$34.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.26 ,$103.55 ,
97035 ULTRASOUND Charge,10526271,CDM,420,RC,97035,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
97110 THERAPY EXERCISE Charge,10524594,CDM,420,RC,97110,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.75 ,75,,,percent of total billed charges,75% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges,$23.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$65.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.24 ,$69.35 ,
97116 GAIT TRAIN Charge,10524574,CDM,420,RC,97116,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
97140 MANUAL THERAPY CHARGE,8960392,CDM,420,RC,97140,HCPCS,outpatient,,,$72.00 ,$25.20 ,,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$54.00 ,75,,,percent of total billed charges,75% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges,$22.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.40 ,
97150 GRP THER 59 Charge,10524576,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
97150 GRP THERAPY Charge,10526259,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
97161 PT EVAL LOW COMPLEX 20 MINS Charge,10524589,CDM,424,RC,97161,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
97162 PT EVAL MOD COMPLEX 30 MINS Charge,10524592,CDM,424,RC,97162,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
97163 PT EVAL HIGH COMPLEX 45 MINS Charge,10524588,CDM,424,RC,97163,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
Group Therapy Charge,8111706,CDM,420,RC,97150,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
"31899 UNLISTED PROCEDURE, TRACHEA, BRONCHI ProFee",31899,CDM,450,RC,31899,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
92526 SPEECH SWALLOW Charge,10524598,CDM,440,RC,92526,HCPCS,outpatient,,,$254.00 ,$88.90 ,,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$195.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$228.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$241.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.53 ,$241.30 ,
99407 SMOKING CESSATION ProFee,30209D,CDM,942,RC,99407,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
"Vital capacity, total 94150",203123,CDM,460,RC,94150,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
BiPAP Charge -> Subsequent,7050,CDM,410,RC,94660,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
Peak Flow Monitoring,8716839,CDM,460,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Peak Flow Monitoring,8716839,CDM,460,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Pulmonary Function Test Pre and Post,12044,CDM,460,RC,94060,HCPCS,outpatient,,,"$1,350.00 ",$472.50 ,,$723.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$723.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$472.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$945.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$945.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,039.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$418.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,215.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$271.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,282.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,255.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$263.25 ,"$1,282.50 ",
Pulmonary Function Test Pre and Post,12044,CDM,460,RC,94060,HCPCS,outpatient,,,$965.25 ,$337.84 ,,$517.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$517.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$723.94 ,75,,,percent of total billed charges,75% of total billed charges,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$772.20 ,80,,,percent of total billed charges,80% of total billed charges,$305.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$337.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$772.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$675.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$675.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$743.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$299.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$868.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$193.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$916.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$897.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$193.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$820.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$188.22 ,$916.99 ,
Pulse Oximetry RT,7019,CDM,460,RC,94760,HCPCS,outpatient,,,$66.00 ,$23.10 ,,$35.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.50 ,75,,,percent of total billed charges,75% of total billed charges,$49.50 ,75,,,percent of total billed charges,75% of total billed charges,$49.50 ,75,,,percent of total billed charges,75% of total billed charges,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.80 ,80,,,percent of total billed charges,80% of total billed charges,$20.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$59.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.87 ,$62.70 ,
RT Incentive Spirometry,12019,CDM,410,RC,94010,HCPCS,outpatient,,,$361.09 ,$126.38 ,,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$270.82 ,75,,,percent of total billed charges,75% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges,$114.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$343.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.41 ,$343.04 ,
19286 US Breast Needle Loc Unilateral Ea Addl,19286,CDM,402,RC,19286,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
70487 CT Maxillofacial w/ Contrast,70487,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
70487 CT Maxillofacial w/ Contrast Rad Charge,70487,CDM,351,RC,70487,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
70487 CT Sinus w/ Contrast,70487,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
70488 CT Maxillofacial w/ + w/o Contrast,70488,CDM,351,RC,70488,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
70552 MRI Brain w/ Contrast,28472,CDM,611,RC,70552,HCPCS,outpatient,,,"$1,740.00 ",$609.00 ,,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$609.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,339.80 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$539.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,566.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,653.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.30 ,"$1,653.00 ",
70553 MRI Brain w/ + w/o Contrast,70553,CDM,611,RC,70553,HCPCS,outpatient,,,"$5,666.00 ","$1,983.10 ",,"$3,036.98 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,036.98 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,532.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,791.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,983.10 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,532.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,966.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,966.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,362.82 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,126.97 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,104.87 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,756.46 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,099.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,137.73 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,382.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,532.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,126.97 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,269.38 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,249.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,137.73 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,816.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,126.97 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,104.87 ","$5,382.70 ",
71045 XR Chest 1 View,71045,CDM,324,RC,71045,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
71046 XR Chest 2 Views,71046,CDM,324,RC,71046,HCPCS,outpatient,,,$315.00 ,$110.25 ,,$168.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.00 ,80,,,percent of total billed charges,80% of total billed charges,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$220.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$242.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$97.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$283.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$299.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.43 ,$299.25 ,
71250 CT Chest w/o Contrast,28012,CDM,352,RC,71250,HCPCS,outpatient,,,"$1,365.00 ",$477.75 ,,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$477.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,051.05 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$423.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,228.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,269.45 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.18 ,"$1,296.75 ",
71275 CT Angio Chest,71275,CDM,352,RC,71275,HCPCS,outpatient,,,"$3,515.00 ","$1,230.25 ",,"$1,884.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,884.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,812.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,111.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,230.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,812.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,460.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,460.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,706.55 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,100.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,089.65 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,163.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$705.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,339.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,812.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$699.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,268.95 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,636.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$705.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,987.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.43 ,"$3,339.25 ",
72040 XR Spine Cervical 2 or 3 Views Rad Charge,72040,CDM,320,RC,72040,HCPCS,outpatient,,,$663.00 ,$232.05 ,,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$232.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$510.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$205.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$596.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$629.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$616.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.29 ,$629.85 ,
72070 XR Spine Thoracic 2 Views,72070,CDM,320,RC,72070,HCPCS,outpatient,,,$434.00 ,$151.90 ,,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$151.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$390.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$412.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.63 ,$412.30 ,
72072 XR Spine Thoracic 3 Views Rad Charge,72072,CDM,320,RC,72072,HCPCS,outpatient,,,$652.00 ,$228.20 ,,$349.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$349.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.60 ,80,,,percent of total billed charges,80% of total billed charges,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$228.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$521.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$456.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$456.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$502.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$202.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$586.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$130.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$619.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.14 ,$619.40 ,
72100 XR Spine Lumbosacral 2 or 3 Views,72100,CDM,320,RC,72100,HCPCS,outpatient,,,$992.84 ,$347.49 ,,$532.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$532.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$794.27 ,80,,,percent of total billed charges,80% of total billed charges,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$347.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$694.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$694.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$764.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$307.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$893.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$199.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$943.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$923.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.60 ,$943.20 ,
72110 XR Spine Lumbosacral 4+ Views Rad Charge,72110,CDM,320,RC,72110,HCPCS,outpatient,,,$860.00 ,$301.00 ,,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$301.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$662.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$266.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$774.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$817.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$799.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$167.70 ,$817.00 ,
72125 CT Spine Cervical w/o Contrast,72125,CDM,352,RC,72125,HCPCS,outpatient,,,"$2,033.00 ",$711.55 ,,"$1,089.69 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,089.69 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,626.40 ",80,,,percent of total billed charges,80% of total billed charges,$642.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$711.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,626.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,423.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,423.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,565.41 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$636.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$630.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,829.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$408.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,931.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,626.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$404.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,890.69 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,524.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$408.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,728.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$396.44 ,"$1,931.35 ",
72131 CT Spine Lumbar w/o Contrast Rad Charge,72131,CDM,352,RC,72131,HCPCS,outpatient,,,"$1,810.00 ",$633.50 ,,$970.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$970.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,448.00 ",80,,,percent of total billed charges,80% of total billed charges,$572.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$633.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,448.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,267.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,267.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,393.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$566.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$561.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,629.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$363.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,719.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,448.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$360.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,683.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,357.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,538.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$352.95 ,"$1,719.50 ",
72146 MRI Spine Thoracic w/o Contrast Rad Charge,72146,CDM,612,RC,72146,HCPCS,outpatient,,,"$4,095.00 ","$1,433.25 ",,"$2,194.92 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,194.92 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,433.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,866.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,866.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,153.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,269.45 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,685.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$822.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,890.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,808.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$822.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$798.53 ,"$3,890.25 ",
72148 MRI Spine Lumbar w/o Contrast Rad Charge,72148,CDM,612,RC,72148,HCPCS,outpatient,,,"$4,112.00 ","$1,439.20 ",,"$2,204.03 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,204.03 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,289.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,300.21 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,439.20 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,289.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,878.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,878.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,166.24 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$817.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,287.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$801.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,274.72 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,700.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$825.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,906.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,289.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$817.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,824.16 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,084.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$825.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,495.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$817.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$801.84 ,"$3,906.40 ",
72158 MRI Spine Lumbar w/ + w/o Contrast Rad Charge,72158,CDM,612,RC,72158,HCPCS,outpatient,,,"$3,168.00 ","$1,108.80 ",,"$1,698.05 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,698.05 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,108.80 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,217.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,217.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,439.36 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$982.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,851.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$636.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,009.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,946.24 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$636.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$617.76 ,"$3,009.60 ",
73030 XR Shoulder Complete 2+ Views Right,73030,CDM,320,RC,73030,HCPCS,outpatient,,,$216.96 ,$75.94 ,,$116.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.72 ,75,,,percent of total billed charges,75% of total billed charges,$162.72 ,75,,,percent of total billed charges,75% of total billed charges,$162.72 ,75,,,percent of total billed charges,75% of total billed charges,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.57 ,80,,,percent of total billed charges,80% of total billed charges,$68.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.94 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$195.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.31 ,$206.11 ,
73110 XR Wrist Complete 3+ Views Left,73110,CDM,320,RC,73110,HCPCS,outpatient,,,$496.32 ,$173.71 ,,$266.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$266.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$372.24 ,75,,,percent of total billed charges,75% of total billed charges,$372.24 ,75,,,percent of total billed charges,75% of total billed charges,$372.24 ,75,,,percent of total billed charges,75% of total billed charges,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.06 ,80,,,percent of total billed charges,80% of total billed charges,$156.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$173.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$397.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$347.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$347.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$382.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$153.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$446.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$99.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$471.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$397.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$461.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$372.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$372.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$372.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$421.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.78 ,$471.50 ,
73140 XR Finger(1st Digit) 2+ Views Left,73140,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
73140 XR Finger(2nd Digit) 2+ Views Left Rad Charge,73140,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
73560 XR Knee 1 or 2 Views Left,73560,CDM,320,RC,73560,HCPCS,outpatient,,,$449.00 ,$157.15 ,,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$345.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$426.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$417.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.56 ,$426.55 ,
73562 XR Knee 3 Views Right,73562,CDM,320,RC,73562,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
73590 XR Tibia/Fibula Right,73590,CDM,320,RC,73590,HCPCS,outpatient,,,$317.00 ,$110.95 ,,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.82 ,$301.15 ,
73610 XR Ankle Complete 3+ Views Left Rad Charge,73610,CDM,320,RC,73610,HCPCS,outpatient,,,$521.00 ,$182.35 ,,$279.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$279.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$390.75 ,75,,,percent of total billed charges,75% of total billed charges,$390.75 ,75,,,percent of total billed charges,75% of total billed charges,$390.75 ,75,,,percent of total billed charges,75% of total billed charges,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$416.80 ,80,,,percent of total billed charges,80% of total billed charges,$164.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$182.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$416.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$364.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$401.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$161.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$468.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$104.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$494.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$484.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$390.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$390.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$390.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$442.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.60 ,$494.95 ,
73620 XR Foot 2 Views RT,18019,CDM,320,RC,73620,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
73620 XR Foot 2 Views Left Rad,736201,CDM,320,RC,73620,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
73630 XR Foot Complete 3+ Views Right,28081,CDM,320,RC,73630,HCPCS,outpatient,,,$394.81 ,$138.18 ,,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$138.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$123.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$122.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$355.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$375.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$367.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.99 ,$375.07 ,
73701 CT Knee  w/ Contrast Right,73701,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
73701 CT Lower Extremity w/ Contrast Bilat,73701,CDM,352,RC,73701,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
73701 CT knee w/ Contrast Left,73701,CDM,352,RC,73701,HCPCS,outpatient,,,$291.00 ,$101.85 ,,$155.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.25 ,75,,,percent of total billed charges,75% of total billed charges,$218.25 ,75,,,percent of total billed charges,75% of total billed charges,$218.25 ,75,,,percent of total billed charges,75% of total billed charges,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.80 ,80,,,percent of total billed charges,80% of total billed charges,$92.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$224.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$90.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$261.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$276.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$218.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$247.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.75 ,$276.45 ,
73702 CT KNEE  BILAT W&WO CONT,73702,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
73702 CT Knee w/+w/o Contrast Left,73702,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
73702 CT Knee w/wo Contrast Right,73702,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
74019 XR Abdomen 2 Views,18009,CDM,320,RC,74019,HCPCS,outpatient,,,$234.00 ,$81.90 ,,$125.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$187.20 ,80,,,percent of total billed charges,80% of total billed charges,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$72.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$210.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$222.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.63 ,$222.30 ,
74160 CT Abdomen w/ Contrast,74160,CDM,352,RC,74160,HCPCS,outpatient,,,"$3,636.00 ","$1,272.60 ",,"$1,948.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,948.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,272.60 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,545.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,545.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,799.72 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$709.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,127.16 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,272.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$730.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,454.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.48 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$730.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$709.02 ,"$3,454.20 ",
74177 CT Abdomen and Pelvis w/ Contrast,74177,CDM,352,RC,74177,HCPCS,outpatient,,,"$6,392.00 ","$2,237.20 ",,"$3,426.11 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,426.11 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,237.20 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,474.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,474.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,921.84 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,246.44 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,981.52 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,752.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,283.51 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,072.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,944.56 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,283.51 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,246.44 ","$6,072.40 ",
74178 CT Abdomen and Pelvis w/ + w/o Contrast,74178,CDM,352,RC,74178,HCPCS,outpatient,,,"$8,929.66 ","$3,125.38 ",,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,125.38 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,875.84 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,795.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,741.28 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,768.19 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$8,036.69 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,483.18 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,304.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,741.28 ","$8,483.18 ",
76536 US Head/Neck Soft Tissue,20011,CDM,402,RC,76536,HCPCS,outpatient,,,$863.00 ,$302.05 ,,$462.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$462.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$647.25 ,75,,,percent of total billed charges,75% of total billed charges,$647.25 ,75,,,percent of total billed charges,75% of total billed charges,$647.25 ,75,,,percent of total billed charges,75% of total billed charges,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$690.40 ,80,,,percent of total billed charges,80% of total billed charges,$272.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$302.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$690.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$604.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$604.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$664.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$270.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$267.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$776.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$173.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$819.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$690.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$802.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$647.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$647.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$647.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$733.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$168.29 ,$819.85 ,
76604 US Chest,28320,CDM,402,RC,76604,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
76641 US Breast Complete Left,20033,CDM,402,RC,76641,HCPCS,outpatient,,,$680.00 ,$238.00 ,,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$238.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$523.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$210.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$612.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$646.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$632.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.60 ,$646.00 ,
76642 US Breast Limited Left,76642,CDM,402,RC,76642,HCPCS,outpatient,,,"$1,019.91 ",$356.97 ,,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$356.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$785.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$316.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$917.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$968.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.88 ,$968.91 ,
76642 US Breast Limited Right,12879,CDM,402,RC,76642,HCPCS,outpatient,,,$736.00 ,$257.60 ,,$394.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$394.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$588.80 ,80,,,percent of total billed charges,80% of total billed charges,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$257.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$588.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$515.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$566.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$228.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$662.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$147.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$699.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$588.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.52 ,$699.20 ,
76642 US Breast Limited Bilat. Rad Charge,76642,CDM,402,RC,76642,HCPCS,outpatient,,,$736.00 ,$257.60 ,,$394.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$394.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$552.00 ,75,,,percent of total billed charges,75% of total billed charges,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$588.80 ,80,,,percent of total billed charges,80% of total billed charges,$232.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$257.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$588.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$515.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$566.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$228.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$662.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$147.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$699.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$588.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$552.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$625.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.52 ,$699.20 ,
76770 US Kidney Bladder,76770,CDM,402,RC,76770,HCPCS,outpatient,,,$295.00 ,$103.25 ,,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$103.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$265.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.53 ,$280.25 ,
76770 US Renal Artery Duplex Bilateral Rad Charge,76770,CDM,402,RC,76770,HCPCS,outpatient,,,$630.00 ,$220.50 ,,$337.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$472.50 ,75,,,percent of total billed charges,75% of total billed charges,$472.50 ,75,,,percent of total billed charges,75% of total billed charges,$472.50 ,75,,,percent of total billed charges,75% of total billed charges,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.00 ,80,,,percent of total billed charges,80% of total billed charges,$199.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$220.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$504.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$441.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$441.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$485.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$195.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$567.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$126.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$598.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$125.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$585.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$472.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$472.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$472.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$535.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.85 ,$598.50 ,
76801 US OB < 14 weeks w/ TVS if indicated Rad Charge,76801,CDM,320,RC,76801,HCPCS,outpatient,,,$325.00 ,$113.75 ,,$174.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$243.75 ,75,,,percent of total billed charges,75% of total billed charges,$243.75 ,75,,,percent of total billed charges,75% of total billed charges,$243.75 ,75,,,percent of total billed charges,75% of total billed charges,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.00 ,80,,,percent of total billed charges,80% of total billed charges,$102.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$113.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$250.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$100.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$292.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$308.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$243.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$276.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.38 ,$308.75 ,
76856 US Pelvic Complete,20008,CDM,402,RC,76856,HCPCS,outpatient,,,$599.00 ,$209.65 ,,$321.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$321.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$449.25 ,75,,,percent of total billed charges,75% of total billed charges,$449.25 ,75,,,percent of total billed charges,75% of total billed charges,$449.25 ,75,,,percent of total billed charges,75% of total billed charges,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.20 ,80,,,percent of total billed charges,80% of total billed charges,$189.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$209.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$479.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$419.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$419.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$461.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$185.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$539.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$120.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$569.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$479.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$449.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$449.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$449.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$509.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$116.81 ,$569.05 ,
77061 MG Diagnostic Right w / tomo,77061,CDM,401,RC,77061,HCPCS,outpatient,,,$565.00 ,$197.75 ,,$302.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$302.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$423.75 ,75,,,percent of total billed charges,75% of total billed charges,$423.75 ,75,,,percent of total billed charges,75% of total billed charges,$423.75 ,75,,,percent of total billed charges,75% of total billed charges,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$452.00 ,80,,,percent of total billed charges,80% of total billed charges,$178.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$197.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$452.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$395.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$395.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$435.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$175.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$508.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$113.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$536.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$112.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$525.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$423.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$423.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$423.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$480.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.18 ,$536.75 ,
77065 MG Mammo Diagnostic Left w/ Tomo. Rad Charge,28738,CDM,401,RC,77065,HCPCS,outpatient,,,$336.00 ,$117.60 ,,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$117.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$104.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$302.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$319.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.52 ,$319.20 ,
77067 MG Mammo Digital Screening Bilateral,77067,CDM,401,RC,77067,HCPCS,outpatient,,,$758.00 ,$265.30 ,,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$265.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$583.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$682.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$720.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.81 ,$720.10 ,
77067 MG Mammo Screening Bilateral w/ Tomo. Rad Charge,77067,CDM,403,RC,77067,HCPCS,outpatient,,,$582.00 ,$203.70 ,,$311.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$311.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$465.60 ,80,,,percent of total billed charges,80% of total billed charges,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$203.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$407.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$448.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$180.42 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$523.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$116.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$552.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$541.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.49 ,$552.90 ,
BD Bone Density DEXA App Skeleton,1167837,CDM,320,RC,77081,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
BD Bone Density DEXA Axial Skeleton,1167839,CDM,320,RC,77080,HCPCS,outpatient,,,$336.05 ,$117.62 ,,$180.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$180.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.04 ,75,,,percent of total billed charges,75% of total billed charges,$252.04 ,75,,,percent of total billed charges,75% of total billed charges,$252.04 ,75,,,percent of total billed charges,75% of total billed charges,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.84 ,80,,,percent of total billed charges,80% of total billed charges,$106.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$117.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$104.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$302.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$67.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$319.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$252.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.53 ,$319.25 ,
BD Bone Density DEXA Vert Fracture Assmt,8211225,CDM,320,RC,77086,HCPCS,outpatient,,,$236.00 ,$82.60 ,,$126.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$188.80 ,80,,,percent of total billed charges,80% of total billed charges,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$82.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$188.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$165.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$181.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$73.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$212.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.02 ,$224.20 ,
CT 3D Reconstruction w/o Workstation,8211228,CDM,352,RC,76376,HCPCS,outpatient,,,$236.00 ,$82.60 ,,$126.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$177.00 ,75,,,percent of total billed charges,75% of total billed charges,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$188.80 ,80,,,percent of total billed charges,80% of total billed charges,$74.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$82.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$188.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$165.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$181.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$73.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$212.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.02 ,$224.20 ,
CT Abdomen and Pelvis w/ + w/o Contrast,28411,CDM,352,RC,74178,HCPCS,outpatient,,,"$8,929.66 ","$3,125.38 ",,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,786.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges,"$2,823.56 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,125.38 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,250.76 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,875.84 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,795.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,795.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,741.28 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,768.19 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$8,036.69 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,483.18 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,143.73 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,304.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,697.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,793.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,590.21 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.11 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,741.28 ","$8,483.18 ",
CT Abdomen and Pelvis w/ Contrast,28410,CDM,352,RC,74177,HCPCS,outpatient,,,"$6,392.00 ","$2,237.20 ",,"$3,426.11 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,426.11 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges,"$2,021.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,237.20 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,474.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,474.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,921.84 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,001.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,246.44 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,981.52 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,752.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,283.51 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,072.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,113.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,944.56 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,794.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,283.51 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,433.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,271.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,246.44 ","$6,072.40 ",
CT Abdomen and Pelvis w/o Contrast,28409,CDM,352,RC,74176,HCPCS,outpatient,,,"$6,168.43 ","$2,158.95 ",,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,158.95 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,749.69 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,931.33 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,202.84 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,912.21 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,551.59 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,860.01 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,736.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,202.84 ","$5,860.01 ",
CT Abdomen w/ + w/o Contrast,28028,CDM,352,RC,74170,HCPCS,outpatient,,,"$3,960.00 ","$1,386.00 ",,"$2,122.56 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,122.56 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,168.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,252.15 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,386.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,168.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,772.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,049.20 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$787.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,239.88 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,227.60 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,564.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$795.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,762.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,168.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$787.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,682.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,970.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$795.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,366.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$787.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$772.20 ,"$3,762.00 ",
CT Abdomen w/ Contrast,28021,CDM,352,RC,74160,HCPCS,outpatient,,,"$3,636.00 ","$1,272.60 ",,"$1,948.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,948.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,149.70 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,272.60 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,545.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,545.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,799.72 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,138.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$709.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,127.16 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,272.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$730.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,454.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,908.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.48 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,727.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$730.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,090.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$723.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$709.02 ,"$3,454.20 ",
CT Abdomen w/o Contrast,28013,CDM,352,RC,74150,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Angio Abdomen,1167853,CDM,352,RC,74175,HCPCS,outpatient,,,"$2,073.00 ",$725.55 ,,"$1,111.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,111.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,658.40 ",80,,,percent of total billed charges,80% of total billed charges,$655.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$725.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,658.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,451.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,451.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,596.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$649.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$642.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,865.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$416.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,969.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,658.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$412.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,927.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,554.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$416.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,762.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$404.24 ,"$1,969.35 ",
CT Angio Abdomen and Pelvis,2424686,CDM,352,RC,74174,HCPCS,outpatient,,,"$2,551.00 ",$892.85 ,,"$1,367.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,367.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges,$806.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$892.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,785.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,785.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,964.27 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$497.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$790.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,295.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$512.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,423.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,372.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,913.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$512.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,168.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$507.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$497.45 ,"$2,423.45 ",
CT Angio Abdomen/Pelvis w/Runoff,9578987,CDM,352,RC,75635,HCPCS,outpatient,,,"$4,882.00 ","$1,708.70 ",,"$2,616.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,616.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,905.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,543.69 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,708.70 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,905.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,417.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,417.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,759.14 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$971.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,528.55 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$951.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,513.42 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,393.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$980.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,637.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,905.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$971.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,540.26 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,661.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$980.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,149.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$971.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$951.99 ,"$4,637.90 ",
CT Angio Brain and Neck,28298D,CDM,351,RC,70496,HCPCS,outpatient,,,"$3,780.00 ","$1,323.00 ",,"$2,026.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,026.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,323.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,646.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,646.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,910.60 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$737.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,171.80 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,402.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$759.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,591.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,515.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$759.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$737.10 ,"$3,591.00 ",
CT Angio Brain/Head,28298,CDM,351,RC,70496,HCPCS,outpatient,,,"$3,780.00 ","$1,323.00 ",,"$2,026.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,026.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,195.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,323.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,646.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,646.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,910.60 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,183.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$737.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,171.80 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,402.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$759.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,591.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,024.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,515.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,835.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$759.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,213.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$751.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$737.10 ,"$3,591.00 ",
CT Angio Chest,1167879,CDM,351,RC,70498,HCPCS,outpatient,,,"$4,515.00 ","$1,580.25 ",,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,580.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,476.55 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$880.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,399.65 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,063.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,289.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,198.95 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$880.43 ,"$4,289.25 ",
CT Angio Chest/Abdomen/Pelvis,28507,CDM,352,RC,71275,HCPCS,outpatient,,,"$4,938.58 ","$1,728.50 ",,"$2,647.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,647.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,728.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,457.01 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,457.01 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,802.71 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,530.96 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,444.72 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$991.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,691.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,592.88 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$991.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$963.02 ,"$4,691.65 ",
CT Angio Lower Extremity Left,1167875,CDM,359,RC,73706,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Angio Lower Extremity Right,1167877,CDM,359,RC,73706,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Angio Lower Extremity Bilateral,8211231,CDM,359,RC,73706,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Angio Neck,28052,CDM,351,RC,70498,HCPCS,outpatient,,,"$4,515.00 ","$1,580.25 ",,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,420.04 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,427.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,580.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,160.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,476.55 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,413.65 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$880.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,399.65 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,063.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,289.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,612.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,198.95 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,386.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$906.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,837.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$898.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$880.43 ,"$4,289.25 ",
CT Angio Pelvis,1167881,CDM,320,RC,72191,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
CT Angio Upper Extremity Left,1167885,CDM,352,RC,73206,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
CT Angio Upper Extremity Right,1167887,CDM,352,RC,73206,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
CT Angio Upper Extremity Bilateral,8426422,CDM,352,RC,73206,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
CT Ankle w/ + w/o Contrast Left,28497D,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,088.00 ",$730.80 ,,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$730.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,607.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$647.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,879.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,983.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,941.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.16 ,"$1,983.60 ",
CT Ankle w/ + w/o Contrast Right,28497,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,088.00 ",$730.80 ,,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$730.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,607.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$647.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,879.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,983.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,941.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.16 ,"$1,983.60 ",
CT Ankle w/ Contrast Left,28043D,CDM,352,RC,73700,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Ankle w/ Contrast Right,28043D2,CDM,352,RC,73700,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Ankle w/o Contrast Left,28043D3,CDM,352,RC,73700,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Ankle w/o Contrast Right,28043D4,CDM,352,RC,73700,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Bone Density Axial Skeleton,1167937,CDM,352,RC,77078,HCPCS,outpatient,,,$471.00 ,$164.85 ,,$252.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.80 ,80,,,percent of total billed charges,80% of total billed charges,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$164.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$329.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$329.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$362.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$423.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$94.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$447.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.85 ,$447.45 ,
CT Brain/Head w/ + w/o Contrast,28015,CDM,351,RC,70470,HCPCS,outpatient,,,"$2,112.00 ",$739.20 ,,"$1,132.03 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,132.03 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,689.60 ",80,,,percent of total billed charges,80% of total billed charges,$667.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$739.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,689.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,478.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,478.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,626.24 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$420.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$654.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,900.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$424.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,006.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,689.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$420.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,964.16 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,584.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$424.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,795.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$420.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$411.84 ,"$2,006.40 ",
CT Brain/Head w/ Contrast,28493,CDM,351,RC,70460,HCPCS,outpatient,,,"$1,196.00 ",$418.60 ,,$641.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$641.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$956.80 ,80,,,percent of total billed charges,80% of total billed charges,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$418.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$956.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$837.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$837.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$920.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$370.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,076.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,136.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$956.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,112.28 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$233.22 ,"$1,136.20 ",
CT Brain/Head w/o Contrast,1168094,CDM,351,RC,70450,HCPCS,outpatient,,,"$1,744.00 ",$610.40 ,,$934.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$934.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,395.20 ",80,,,percent of total billed charges,80% of total billed charges,$551.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$610.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,395.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,220.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,220.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,342.88 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$546.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$540.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,569.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$350.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,656.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,621.92 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,308.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$350.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,482.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.08 ,"$1,656.80 ",
CT Chest High Resolution,2424752,CDM,352,RC,71250,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Chest PE Protocol,9066871,CDM,352,RC,71275,HCPCS,outpatient,,,"$4,938.58 ","$1,728.50 ",,"$2,647.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,647.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges,"$1,561.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,728.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,457.01 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,457.01 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,802.71 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,546.27 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,530.96 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,444.72 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$991.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,691.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,950.86 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,592.88 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,703.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$991.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,197.79 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$982.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$963.02 ,"$4,691.65 ",
CT Chest w/ + w/o Contrast,28025,CDM,352,RC,71270,HCPCS,outpatient,,,"$1,926.00 ",$674.10 ,,"$1,032.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,032.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$674.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,348.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,483.02 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$597.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,733.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$386.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,829.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,791.18 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$386.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.57 ,"$1,829.70 ",
CT Chest w/ Contrast,28027,CDM,352,RC,71260,HCPCS,outpatient,,,"$4,554.80 ","$1,594.18 ",,"$2,441.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,441.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,594.18 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,188.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,188.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,507.20 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$888.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,411.99 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,099.32 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$914.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,327.06 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,235.96 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$914.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$888.19 ,"$4,327.06 ",
CT Chest w/contrast,28027,CDM,352,RC,71260,HCPCS,outpatient,,,"$4,554.80 ","$1,594.18 ",,"$2,441.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,441.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges,"$1,440.23 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,594.18 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,188.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,188.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,507.20 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,426.11 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$888.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,411.99 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,099.32 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$914.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,327.06 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,643.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,235.96 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,416.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$914.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,871.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$905.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$888.19 ,"$4,327.06 ",
CT Chest w/o Contrast,28012,CDM,352,RC,71250,HCPCS,outpatient,,,$975.98 ,$341.59 ,,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$341.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$751.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$302.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$878.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$927.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.32 ,$927.18 ,
CT Chest/Abd/Pelvis w/ + w/o Contrast,28025,CDM,352,RC,71270,HCPCS,outpatient,,,"$1,926.00 ",$674.10 ,,"$1,032.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,032.34 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges,$609.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$674.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,348.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,483.02 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$603.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$597.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,733.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$386.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,829.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,791.18 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,444.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$386.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,637.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.57 ,"$1,829.70 ",
CT Chest/Abd/Pelvis w/o Contrast,28012,CDM,352,RC,71250,HCPCS,outpatient,,,$975.98 ,$341.59 ,,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$341.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$751.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$302.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$878.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$927.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.32 ,$927.18 ,
CT Elbow w/ + w/o Contrast Left,28048D,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Elbow w/ + w/o Contrast Right,28048D2,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Elbow w/ Contrast Left,28282D,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Elbow w/ Contrast Right,28282D2,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Elbow w/o Contrast Left,28048D11,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Elbow w/o Contrast Right,28048D4,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Femur w/ + w/o Contrast Left,28032D,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Femur w/ + w/o Contrast Right,28032D2,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Femur w/ Contrast Left,28043D6,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Femur w/ Contrast Right,28043D5,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Femur w/o Contrast Left,28011D,CDM,359,RC,73700,HCPCS,outpatient,,,$584.00 ,$204.40 ,,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$204.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$449.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$181.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$525.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$543.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.88 ,$554.80 ,
CT Femur w/o Contrast Right,28011D2,CDM,359,RC,73700,HCPCS,outpatient,,,$584.00 ,$204.40 ,,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$204.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$449.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$181.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$525.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$543.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.88 ,$554.80 ,
CT Foot w/ + w/o Contrast Left,28032D3,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Foot w/ + w/o Contrast Right,28032D4,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Foot w/ Contrast Left,1168034,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,593.00 ",$907.55 ,,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$907.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,996.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$803.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,333.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,463.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,411.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$505.64 ,"$2,463.35 ",
CT Foot w/ Contrast Right,1168036,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,593.00 ",$907.55 ,,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$907.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,996.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$803.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,333.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,463.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,411.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$505.64 ,"$2,463.35 ",
CT Foot w/o Contrast Left,1168040,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,593.00 ",$907.55 ,,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$907.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,996.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$803.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,333.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,463.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,411.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$505.64 ,"$2,463.35 ",
CT Foot w/o Contrast Right,1168042,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,593.00 ",$907.55 ,,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,389.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges,$819.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$907.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,815.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,996.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$811.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$803.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,333.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,463.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,411.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,944.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$520.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,204.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$505.64 ,"$2,463.35 ",
CT Forearm w/ + w/o Contrast Left,28048D3,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Forearm w/ + w/o Contrast Right,28048D6,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Forearm w/ Contrast Left,8099819,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Forearm w/ Contrast Right,8099821,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Forearm w/o Contrast Left,8099823,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Forearm w/o Contrast Right,8099825,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Hand w/ + w/o Contrast Left,20395,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
CT Hand w/ + w/o Contrast Right,20396,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
CT Hand w/ Contrast Left,28282D3,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Hand w/ Contrast Right,28282D4,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Hand w/o Contrast Left,28048D7,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Hand w/o Contrast Right,28048D8,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Head Stroke Protocol,203120,CDM,351,RC,70450,HCPCS,outpatient,,,"$1,246.96 ",$436.44 ,,$668.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$668.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$935.22 ,75,,,percent of total billed charges,75% of total billed charges,$935.22 ,75,,,percent of total billed charges,75% of total billed charges,$935.22 ,75,,,percent of total billed charges,75% of total billed charges,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$997.57 ,80,,,percent of total billed charges,80% of total billed charges,$394.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$436.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$390.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$997.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$872.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$872.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$960.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$390.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$390.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$386.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,122.26 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$250.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,184.61 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$997.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,159.67 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$935.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$250.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,059.92 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.16 ,"$1,184.61 ",
CT Head w/ Contrast,8211240,CDM,351,RC,70460,HCPCS,outpatient,,,"$1,196.00 ",$418.60 ,,$641.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$641.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$897.00 ,75,,,percent of total billed charges,75% of total billed charges,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$956.80 ,80,,,percent of total billed charges,80% of total billed charges,$378.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$418.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$956.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$837.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$837.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$920.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$374.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$370.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,076.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,136.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$956.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,112.28 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$897.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,016.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$233.22 ,"$1,136.20 ",
CT Hip w/ + w/o Contrast Left,28032D6,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Hip w/ + w/o Contrast Right,28032D7,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Hip w/ Contrast Left,28043,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Hip w/ Contrast Right,28043D7,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Hip w/o Contrast Left,1168116,CDM,359,RC,73700,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
CT Hip w/o Contrast Right,1168118,CDM,359,RC,73700,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
CT Humerus w/ + w/o Contrast Left,20397,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,251.00 ",$437.85 ,,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$437.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$963.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$387.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,125.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,188.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,163.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.95 ,"$1,188.45 ",
CT Humerus w/ + w/o Contrast Right,20398,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,251.00 ",$437.85 ,,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$437.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$963.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$387.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,125.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,188.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,163.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.95 ,"$1,188.45 ",
CT Humerus w/ Contrast Left,28282D5,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Humerus w/ Contrast Right,28282D6,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Humerus w/o Contrast Left,8099843,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,017.00 ",$355.95 ,,$545.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$545.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$813.60 ,80,,,percent of total billed charges,80% of total billed charges,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$355.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$813.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$711.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$783.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$315.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$915.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$204.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$966.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$813.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$945.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.32 ,$966.15 ,
CT Humerus w/o Contrast Right,8099845,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,017.00 ",$355.95 ,,$545.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$545.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$762.75 ,75,,,percent of total billed charges,75% of total billed charges,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$813.60 ,80,,,percent of total billed charges,80% of total billed charges,$321.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$355.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$813.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$711.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$783.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$315.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$915.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$204.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$966.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$813.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$945.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$762.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$864.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.32 ,$966.15 ,
CT Knee w/ + w/o Contrast Left,73702,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Knee w/ + w/o Contrast Right,73702,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Knee w/ Contrast Left,73701,CDM,359,RC,73701,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Knee w/ Contrast Right,73701,CDM,359,RC,73701,HCPCS,outpatient,,,"$2,525.00 ",$883.75 ,,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,353.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges,$798.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$883.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,767.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,944.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$790.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$782.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,272.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,398.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,020.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,348.25 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,893.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$507.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,146.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$492.38 ,"$2,398.75 ",
CT Knee w/o Contrast Right,73700,CDM,359,RC,73700,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
CT Knee w/o Contrast Left,737001,CDM,359,RC,73700,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
CT Knee w/o Contrast Right,73700,CDM,359,RC,73700,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
CT Low Dose Count Screening,28915,CDM,352,RC,71271,HCPCS,outpatient,,,"$1,365.00 ",$477.75 ,,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$477.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,051.05 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$423.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,228.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,269.45 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.18 ,"$1,296.75 ",
CT Low Dose Lung Screening,28915,CDM,352,RC,71271,HCPCS,outpatient,,,$975.98 ,$341.59 ,,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$523.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$731.99 ,75,,,percent of total billed charges,75% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges,$308.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$341.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$683.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$751.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$302.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$878.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$927.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$780.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$731.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$829.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.32 ,$927.18 ,
CT Low Dose lung Screening,28915,CDM,352,RC,71271,HCPCS,outpatient,,,"$1,365.00 ",$477.75 ,,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$477.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,051.05 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$423.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,228.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,269.45 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.18 ,"$1,296.75 ",
CT Lower Extremity w/ Contrast Bilat,1168164,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Lower Extremity w/ Contrast Left,1168166,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Lower Extremity w/ Contrast Right,1168168,CDM,352,RC,73701,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Lower Extremity w/+w/o Contrast Bilat,1168170,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
CT Lower Extremity w/+w/o Contrast Left,1168172,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
CT Lower Extremity w/+w/o Contrast Right,1168174,CDM,352,RC,73702,HCPCS,outpatient,,,"$2,175.00 ",$761.25 ,,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges,$687.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$761.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,522.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,674.75 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$674.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,957.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,066.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,740.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,022.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,631.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,848.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$424.13 ,"$2,066.25 ",
CT Lower Extremity w/o Contrast Bilat,1168176,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,088.00 ",$730.80 ,,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$730.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,607.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$647.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,879.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,983.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,941.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.16 ,"$1,983.60 ",
CT Lower Extremity w/o Contrast Left,1168178,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,088.00 ",$730.80 ,,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$730.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,607.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$647.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,879.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,983.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,941.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.16 ,"$1,983.60 ",
CT Lower Extremity w/o Contrast Right,1168180,CDM,359,RC,73700,HCPCS,outpatient,,,"$2,088.00 ",$730.80 ,,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,119.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges,$660.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$730.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,461.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,607.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$653.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$647.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,879.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,983.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,670.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,941.84 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,566.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$419.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,774.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$415.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.16 ,"$1,983.60 ",
CT Lung Cancer Screening,28915,CDM,352,RC,71271,HCPCS,outpatient,,,"$1,365.00 ",$477.75 ,,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$477.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,051.05 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$423.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,228.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,269.45 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.18 ,"$1,296.75 ",
CT Maxillofacial w/ Contrast,70487,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
CT Maxillofacial w/ + w/o Contrast,8100151,CDM,351,RC,70488,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
CT Maxillofacial w/ Contrast,70487,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
CT Maxillofacial w/ Contrast,70487,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
CT Maxillofacial w/o Contrast,1168186,CDM,351,RC,70486,HCPCS,outpatient,,,"$2,059.20 ",$720.72 ,,"$1,103.73 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,103.73 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$720.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.44 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,441.44 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,585.58 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$644.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$638.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,853.28 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$413.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,956.24 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.06 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$413.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$401.54 ,"$1,956.24 ",
CT Neck Soft Tissue w/ + w/o Contrast,28044,CDM,351,RC,70492,HCPCS,outpatient,,,"$3,601.00 ","$1,260.35 ",,"$1,930.14 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,930.14 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,880.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,138.64 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,260.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,880.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,520.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,520.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,772.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,127.47 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,116.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,240.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,420.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,880.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,348.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,700.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,060.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.20 ,"$3,420.95 ",
CT Neck Soft Tissue w/ Contrast,28026,CDM,351,RC,70491,HCPCS,outpatient,,,"$4,153.20 ","$1,453.62 ",,"$2,226.12 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,226.12 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,322.56 ",80,,,percent of total billed charges,80% of total billed charges,"$1,313.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,453.62 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,300.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,322.56 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,907.24 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,907.24 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,197.96 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,300.36 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$826.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,300.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,300.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,300.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,300.37 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$809.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,287.49 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,737.88 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$833.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,945.54 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,322.56 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$826.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,862.48 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,114.90 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$833.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,530.22 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$826.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$809.87 ,"$3,945.54 ",
CT Neck Soft Tissue w/o Contrast,28006,CDM,351,RC,70490,HCPCS,outpatient,,,"$1,620.00 ",$567.00 ,,$868.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$868.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,296.00 ",80,,,percent of total billed charges,80% of total billed charges,$512.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$567.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,296.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,134.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,247.40 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$322.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$507.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$502.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,458.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$325.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,539.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,296.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$322.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,506.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,215.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$322.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.90 ,"$1,539.00 ",
CT Orbits Sella w/ + w/o Contrast,1168188,CDM,351,RC,70482,HCPCS,outpatient,,,"$1,449.00 ",$507.15 ,,$776.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$776.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,159.20 ",80,,,percent of total billed charges,80% of total billed charges,$458.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,159.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,014.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,014.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,115.73 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$453.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,304.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$290.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,376.55 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,159.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,347.57 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,086.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$290.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,231.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.56 ,"$1,376.55 ",
CT Orbits Sella w/ Contrast,28037,CDM,351,RC,70481,HCPCS,outpatient,,,"$1,649.90 ",$577.47 ,,$884.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$884.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,319.92 ",80,,,percent of total billed charges,80% of total billed charges,$521.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$577.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,319.92 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.93 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,154.93 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,270.42 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$516.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$511.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,484.91 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$331.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,567.41 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,319.92 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$328.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,534.41 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,237.43 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$331.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,402.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$321.73 ,"$1,567.41 ",
CT Orbits Sella w/o Contrast,1168192,CDM,351,RC,70480,HCPCS,outpatient,,,"$1,402.90 ",$491.02 ,,$751.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$751.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,122.32 ",80,,,percent of total billed charges,80% of total billed charges,$443.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$491.02 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,122.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$982.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$982.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,080.23 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$273.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$434.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,262.61 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$281.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,332.76 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,122.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$279.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,304.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,052.18 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,192.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$273.57 ,"$1,332.76 ",
CT Pelvis w/ + w/o Contrast,1168194,CDM,352,RC,72194,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
CT Pelvis w/ Contrast,1168196,CDM,352,RC,72193,HCPCS,outpatient,,,"$1,435.00 ",$502.25 ,,$769.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$769.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$502.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,004.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,104.95 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$444.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,291.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$288.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,363.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,334.55 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$279.83 ,"$1,363.25 ",
CT Pelvis w/o Contrast,1168198,CDM,352,RC,72192,HCPCS,outpatient,,,"$1,166.17 ",$408.16 ,,$625.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$625.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$874.63 ,75,,,percent of total billed charges,75% of total billed charges,$874.63 ,75,,,percent of total billed charges,75% of total billed charges,$874.63 ,75,,,percent of total billed charges,75% of total billed charges,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$932.94 ,80,,,percent of total billed charges,80% of total billed charges,$368.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$408.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$932.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$816.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$897.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$361.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,049.55 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$234.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,107.86 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$932.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,084.54 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$874.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$874.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$874.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$234.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$991.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$227.40 ,"$1,107.86 ",
CT Renal w/ + w/o Contrast,9042464,CDM,352,RC,74170,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
CT Shoulder w/ + w/o Contrast Left,28048D9,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Shoulder w/ + w/o Contrast Right,28048,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Shoulder w/ Contrast Left,28282D7,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Shoulder w/ Contrast Right,28282D8,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Shoulder w/o Contrast Left,1168220,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,674.00 ",$935.90 ,,"$1,433.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,433.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$935.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,871.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,871.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,058.98 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$828.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,406.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$536.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,540.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,486.82 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$536.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$521.43 ,"$2,540.30 ",
CT Shoulder w/o Contrast Right,1168222,CDM,359,RC,73200,HCPCS,outpatient,,,"$2,674.00 ",$935.90 ,,"$1,433.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,433.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges,$845.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$935.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,871.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,871.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,058.98 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$837.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$828.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,406.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$536.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,540.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,139.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,486.82 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,005.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$536.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,272.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$521.43 ,"$2,540.30 ",
CT Sinus w/ +  w/o Contrast,8100151,CDM,351,RC,70488,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
CT Sinus w/ Contrast,8100154,CDM,351,RC,70487,HCPCS,outpatient,,,"$3,604.00 ","$1,261.40 ",,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,931.74 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,139.58 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,261.40 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,522.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,775.08 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,128.41 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,117.24 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,243.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,423.80 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,883.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,351.72 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,703.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,063.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.78 ,"$3,423.80 ",
CT Sinus w/o Contrast,1168228,CDM,351,RC,70486,HCPCS,outpatient,,,"$2,059.20 ",$720.72 ,,"$1,103.73 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,103.73 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges,$651.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$720.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.44 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,441.44 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,585.58 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$644.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$401.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$638.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,853.28 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$413.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,956.24 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,647.36 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.06 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,544.40 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$413.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,750.32 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$409.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$401.54 ,"$1,956.24 ",
CT Spine Cervical w/ + w/o Contrast,20399,CDM,352,RC,72127,HCPCS,outpatient,,,"$2,050.00 ",$717.50 ,,"$1,098.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,098.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,640.00 ",80,,,percent of total billed charges,80% of total billed charges,$648.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$717.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,640.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,435.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,435.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,578.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$641.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$399.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$635.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,845.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$411.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,947.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,640.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$407.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,906.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,537.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,742.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$399.75 ,"$1,947.50 ",
CT Spine Cervical w/ Contrast,28017,CDM,350,RC,72126,HCPCS,outpatient,,,"$1,296.00 ",$453.60 ,,$694.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$694.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$972.00 ,75,,,percent of total billed charges,75% of total billed charges,$972.00 ,75,,,percent of total billed charges,75% of total billed charges,$972.00 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,036.80 ",80,,,percent of total billed charges,80% of total billed charges,$409.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$453.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,036.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$907.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$997.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$405.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$401.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,166.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$260.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,231.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,036.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$257.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,205.28 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$972.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$972.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$972.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$260.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,101.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.72 ,"$1,231.20 ",
CT Spine Cervical w/o Contrast,28008,CDM,352,RC,72125,HCPCS,outpatient,,,"$1,453.60 ",$508.76 ,,$779.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$779.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,162.88 ",80,,,percent of total billed charges,80% of total billed charges,$459.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$508.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$455.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,162.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,017.52 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,017.52 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,119.27 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$455.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$455.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$455.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$455.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$455.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$450.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,308.24 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,380.92 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$289.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.85 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,090.20 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,235.56 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$283.45 ,"$1,380.92 ",
CT Spine Lumbar w/ + w/o Contrast,1168242,CDM,352,RC,72133,HCPCS,outpatient,,,"$3,770.00 ","$1,319.50 ",,"$2,020.72 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,020.72 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,016.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,192.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,319.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,016.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,639.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,639.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,902.90 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$749.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,180.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$735.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,168.70 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,393.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$757.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,581.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,016.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$749.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,506.10 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,827.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$757.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,204.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$749.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$735.15 ,"$3,581.50 ",
CT Spine Lumbar w/ Contrast,1168244,CDM,352,RC,72132,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
CT Spine Lumbar w/o Contrast,1168246,CDM,352,RC,72131,HCPCS,outpatient,,,"$2,543.05 ",$890.07 ,,"$1,363.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,363.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,034.44 ",80,,,percent of total billed charges,80% of total billed charges,$804.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$890.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,034.44 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,780.14 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,780.14 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,958.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$796.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$495.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$788.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,288.75 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$510.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,415.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,034.44 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$505.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,365.04 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,907.29 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,161.59 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$495.89 ,"$2,415.90 ",
CT Spine Thoracic w/ + w/o Contrast,1168248,CDM,352,RC,72130,HCPCS,outpatient,,,"$1,812.00 ",$634.20 ,,$971.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$971.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,449.60 ",80,,,percent of total billed charges,80% of total billed charges,$572.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$634.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,449.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,268.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,268.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,395.24 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$567.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$561.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,630.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$363.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,721.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,449.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$360.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,685.16 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,359.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,540.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$353.34 ,"$1,721.40 ",
CT Spine Thoracic w/ Contrast,1168250,CDM,352,RC,72129,HCPCS,outpatient,,,"$1,685.00 ",$589.75 ,,$903.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$903.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,348.00 ",80,,,percent of total billed charges,80% of total billed charges,$532.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$589.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,348.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,179.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,179.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,297.45 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$527.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$522.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,516.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$338.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,600.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$335.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,567.05 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,263.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$338.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,432.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$328.58 ,"$1,600.75 ",
CT Spine Thoracic w/o Contrast,1168252,CDM,352,RC,72128,HCPCS,outpatient,,,"$2,736.94 ",$957.93 ,,"$1,467.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,467.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,189.55 ",80,,,percent of total billed charges,80% of total billed charges,$865.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$957.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$856.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,189.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,915.86 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,915.86 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,107.44 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$856.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$856.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$856.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$856.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$856.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$533.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$848.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,463.25 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$549.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,600.09 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,189.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$544.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,545.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,052.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$549.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,326.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$533.70 ,"$2,600.09 ",
CT Stone Protocol,28502,CDM,352,RC,74176,HCPCS,outpatient,,,"$6,168.43 ","$2,158.95 ",,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,306.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges,"$1,950.46 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,158.95 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,317.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,749.69 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,931.33 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,931.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,202.84 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,912.21 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,551.59 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,860.01 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,934.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,736.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,626.32 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,238.62 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,243.17 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,202.84 ","$5,860.01 ",
CT Tibia/Fibula w/ + w/o Contrast Right,28032,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Tibia/Fibula w/ Contrast Left,28043D8,CDM,352,RC,73201,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Tibia/Fibula w/ Contrast Right,28043D9,CDM,352,RC,73201,HCPCS,outpatient,,,"$2,691.00 ",$941.85 ,,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,442.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges,$850.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$941.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,883.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,072.07 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$842.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$834.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,421.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,556.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,502.63 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,018.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,287.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$524.75 ,"$2,556.45 ",
CT Tibia/Fibula w/o Contrast Right,28011D4,CDM,359,RC,73200,HCPCS,outpatient,,,$584.00 ,$204.40 ,,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$204.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$449.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$181.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$525.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$543.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.88 ,$554.80 ,
CT Tibia/Fibula w/ + w/o Contrast Left,28032D8,CDM,359,RC,73702,HCPCS,outpatient,,,"$2,538.00 ",$888.30 ,,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,360.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges,$802.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$888.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,776.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,954.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$786.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,284.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,411.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,030.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,360.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,903.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$509.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,157.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.91 ,"$2,411.10 ",
CT Tibia/Fibula w/o Contrast Left,28011,CDM,359,RC,73200,HCPCS,outpatient,,,$584.00 ,$204.40 ,,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$313.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$438.00 ,75,,,percent of total billed charges,75% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges,$184.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$204.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$449.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$181.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$525.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$467.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$543.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$438.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$496.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.88 ,$554.80 ,
CT Upper Extremity w/ Contrast Left,1168311,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Upper Extremity w/ Contrast Right,1168313,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Upper Extremity w/o Contrast Left,1168323,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Upper Extremity w/o Contrast Right,1168325,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,221.00 ",$427.35 ,,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$654.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$915.75 ,75,,,percent of total billed charges,75% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges,$386.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$940.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,135.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$245.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.10 ,"$1,159.95 ",
CT Wrist w/ + w/o Contrast Left,203100,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
CT Wrist w/ + w/o Contrast Right,203101,CDM,359,RC,73202,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
CT Wrist w/ Contrast Left,28282D9,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Wrist w/ Contrast Right,28282,CDM,359,RC,73201,HCPCS,outpatient,,,"$1,555.00 ",$544.25 ,,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$833.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges,$491.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$544.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,197.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$482.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,399.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,477.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,244.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,446.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,166.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,321.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.23 ,"$1,477.25 ",
CT Wrist w/o Contrast Left,1168341,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,251.00 ",$437.85 ,,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$437.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$963.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$387.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,125.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,188.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,163.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.95 ,"$1,188.45 ",
CT Wrist w/o Contrast Right,1168343,CDM,359,RC,73200,HCPCS,outpatient,,,"$1,251.00 ",$437.85 ,,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$670.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$938.25 ,75,,,percent of total billed charges,75% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges,$395.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$437.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$875.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$963.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$391.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$387.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,125.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,188.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,000.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,163.43 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$938.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$251.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,063.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.95 ,"$1,188.45 ",
DXA BONE DENSITY,77080,CDM,320,RC,77080,HCPCS,outpatient,,,$451.20 ,$157.92 ,,$241.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$338.40 ,75,,,percent of total billed charges,75% of total billed charges,$338.40 ,75,,,percent of total billed charges,75% of total billed charges,$338.40 ,75,,,percent of total billed charges,75% of total billed charges,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.96 ,80,,,percent of total billed charges,80% of total billed charges,$142.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$347.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$406.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$428.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$419.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$338.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$338.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$338.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$383.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,$428.64 ,
Echocardiogram M Mode  & 2D,93306,CDM,483,RC,93306,HCPCS,outpatient,,,"$2,807.00 ",$982.45 ,,"$1,504.55 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,504.55 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,245.60 ",80,,,percent of total billed charges,80% of total billed charges,$887.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$982.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,245.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,964.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,964.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,161.39 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$558.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$878.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$870.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,526.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$563.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,666.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,245.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$558.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,610.51 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,105.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$563.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,385.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$558.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$547.37 ,"$2,666.65 ",
MG Mammo Diagnostic Bilateral w/ Tomo,77067,CDM,403,RC,77067,HCPCS,outpatient,,,$582.00 ,$203.70 ,,$311.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$311.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$436.50 ,75,,,percent of total billed charges,75% of total billed charges,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$465.60 ,80,,,percent of total billed charges,80% of total billed charges,$184.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$203.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$407.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$448.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$180.42 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$523.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$116.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$552.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$541.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$436.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$494.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.49 ,$552.90 ,
MG Mammo Diagnostic Bilateral w/ Tomo,8420275,CDM,401,RC,77066,HCPCS,outpatient,,,$765.00 ,$267.75 ,,$410.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$410.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$612.00 ,80,,,percent of total billed charges,80% of total billed charges,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$267.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$535.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$688.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$153.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$726.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.18 ,$726.75 ,
MG Mammo Diagnostic Left w/ Tomo,8420278,CDM,401,RC,77065,HCPCS,outpatient,,,$767.60 ,$268.66 ,,$411.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$614.08 ,80,,,percent of total billed charges,80% of total billed charges,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$614.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$537.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$591.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$690.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$154.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$729.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$614.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.68 ,$729.22 ,
MG Mammo Diagnostic Right w/ Tomo,8420281,CDM,401,RC,77065,HCPCS,outpatient,,,$767.60 ,$268.66 ,,$411.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$575.70 ,75,,,percent of total billed charges,75% of total billed charges,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$614.08 ,80,,,percent of total billed charges,80% of total billed charges,$242.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$614.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$537.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$591.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$690.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$154.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$729.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$614.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$652.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.68 ,$729.22 ,
MG Mammo Digital Diagnostic Bilat,969799,CDM,401,RC,77066,HCPCS,outpatient,,,$576.80 ,$201.88 ,,$309.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.60 ,75,,,percent of total billed charges,75% of total billed charges,$432.60 ,75,,,percent of total billed charges,75% of total billed charges,$432.60 ,75,,,percent of total billed charges,75% of total billed charges,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.44 ,80,,,percent of total billed charges,80% of total billed charges,$182.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$201.88 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$461.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$403.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$444.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$178.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$519.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$115.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$547.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$461.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$432.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$432.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$432.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$490.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.48 ,$547.96 ,
MG Mammo Digital Diagnostic Left,969801,CDM,401,RC,77065,HCPCS,outpatient,,,$336.00 ,$117.60 ,,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$117.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$104.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$302.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$319.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.52 ,$319.20 ,
MG Mammo Digital Diagnostic Right,969803,CDM,401,RC,77065,HCPCS,outpatient,,,$336.00 ,$117.60 ,,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$180.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$252.00 ,75,,,percent of total billed charges,75% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges,$106.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$117.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$104.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$302.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$319.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.52 ,$319.20 ,
MG Mammo Digital Screening Bilateral,969805,CDM,403,RC,77067,HCPCS,outpatient,,,$758.00 ,$265.30 ,,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$265.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$583.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$682.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$720.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.81 ,$720.10 ,
MG Mammo Screening Bilateral w/ Tomo,969805,CDM,403,RC,77067,HCPCS,outpatient,,,$758.00 ,$265.30 ,,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$265.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$583.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$682.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$720.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.81 ,$720.10 ,
MG Mammo Screening Left w/ Tomo,8420276,CDM,401,RC,77067,HCPCS,outpatient,,,$758.00 ,$265.30 ,,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$265.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$583.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$682.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$720.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.81 ,$720.10 ,
MG Mammo Screening Right w/ Tomo,8420277,CDM,401,RC,77067,HCPCS,outpatient,,,$758.00 ,$265.30 ,,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$406.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$568.50 ,75,,,percent of total billed charges,75% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges,$239.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$265.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$530.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$583.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$237.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$682.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$720.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$568.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$644.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.81 ,$720.10 ,
MISC,18006,CDM,320,RC,74220,HCPCS,outpatient,,,"$2,397.00 ",$838.95 ,,"$1,284.79 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,284.79 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,917.60 ",80,,,percent of total billed charges,80% of total billed charges,$757.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$838.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,917.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,677.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,677.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,845.69 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$750.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$467.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$743.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,157.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$481.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,277.15 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,917.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$476.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,229.21 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,797.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$481.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,037.45 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$467.42 ,"$2,277.15 ",
MRA Abdomen w/ + w/o Contrast,1168635,CDM,614,RC,74185,HCPCS,outpatient,,,"$4,147.00 ","$1,451.45 ",,"$2,222.79 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,222.79 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,317.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,311.28 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,451.45 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,317.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,902.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,902.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,193.19 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,298.43 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$808.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,285.57 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,732.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$832.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,939.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,317.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$824.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,856.71 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,110.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$832.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,524.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$808.67 ,"$3,939.65 ",
MRA Abdomen w/o Contrast,1168639,CDM,614,RC,74185,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Brain/Head w/ + w/o Contrast,1168649,CDM,611,RC,70546,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Brain/Head w/o Contrast,1168653,CDM,615,RC,70544,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Chest w/ + w/o Contrast,1168643,CDM,614,RC,71555,HCPCS,outpatient,,,"$2,320.00 ",$812.00 ,,"$1,243.52 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,243.52 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,856.00 ",80,,,percent of total billed charges,80% of total billed charges,$733.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$812.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,856.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,624.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,624.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,786.40 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$461.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$719.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,088.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$465.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,204.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,856.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$461.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,157.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,740.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$465.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,972.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$461.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$452.40 ,"$2,204.00 ",
MRA Lower Extremity w/ + w/o Cnt Left,1168663,CDM,616,RC,73725,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Lower Extremity w/ + w/o Cnt Right,1168665,CDM,616,RC,73725,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Neck w/ + w/o Contrast,1168679,CDM,615,RC,70549,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Neck w/o Contrast,1168683,CDM,615,RC,70547,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Pelvis w/ + w/o Contrast,1168687,CDM,618,RC,72198,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Upper Extremity w/ + w/o Cnt Left,28360D,CDM,616,RC,73725,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRA Upper Extremity w/ + w/o Cnt Right,28360,CDM,616,RC,73725,HCPCS,outpatient,,,"$3,190.00 ","$1,116.50 ",,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,709.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,008.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,116.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,233.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,456.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$998.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$988.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,871.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,030.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,552.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,966.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,392.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$640.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,711.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$634.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$622.05 ,"$3,030.50 ",
MRI Abdomen w/ + w/o Contrast,1168730,CDM,614,RC,74183,HCPCS,outpatient,,,"$5,910.00 ","$2,068.50 ",,"$3,167.76 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,167.76 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,728.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,868.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,068.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,728.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,137.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,137.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,550.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,175.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,850.42 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,152.45 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,832.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,319.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,186.73 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,614.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,728.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,175.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,496.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,432.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,186.73 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,023.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,175.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,152.45 ","$5,614.50 ",
MRI Abdomen w/ Contrast,203102,CDM,614,RC,74182,HCPCS,outpatient,,,"$1,400.00 ",$490.00 ,,$750.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$750.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$490.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$980.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$980.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,078.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$273.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$434.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,260.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$281.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,330.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,302.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$273.00 ,"$1,330.00 ",
MRI Abdomen w/o Contrast,1168734,CDM,614,RC,74181,HCPCS,outpatient,,,"$1,435.00 ",$502.25 ,,$769.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$769.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges,$453.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$502.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,004.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,104.95 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$449.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$444.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,291.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$288.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,363.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,148.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,334.55 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,076.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,219.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$285.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$279.83 ,"$1,363.25 ",
MRI Ankle w/ + w/o Contrast Left,1168738,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Ankle w/ + w/o Contrast Right,1168740,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Ankle w/ Contrast Left,28358D,CDM,610,RC,73721,HCPCS,outpatient,,,"$3,941.00 ","$1,379.35 ",,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,379.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,034.57 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$768.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,221.71 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,546.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,743.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,665.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$768.50 ,"$3,743.95 ",
MRI Ankle w/ Contrast Right,28358,CDM,610,RC,73721,HCPCS,outpatient,,,"$3,941.00 ","$1,379.35 ",,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,379.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,034.57 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$768.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,221.71 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,546.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,743.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,665.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$768.50 ,"$3,743.95 ",
MRI Ankle w/o Contrast Left,1168750,CDM,610,RC,73721,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Ankle w/o Contrast Right,1168752,CDM,610,RC,73721,HCPCS,outpatient,,,"$3,941.00 ","$1,379.35 ",,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,112.38 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,246.14 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,379.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,758.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,034.57 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,233.93 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$768.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,221.71 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,546.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,743.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,152.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,665.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,955.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$791.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,349.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$768.50 ,"$3,743.95 ",
MRI Brain w/ + w/o Contrast,1168796,CDM,611,RC,70553,HCPCS,outpatient,,,"$7,413.26 ","$2,594.64 ",,"$3,973.51 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,973.51 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,930.61 ",80,,,percent of total billed charges,80% of total billed charges,"$2,344.07 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,594.64 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,930.61 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,189.28 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,189.28 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,708.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,474.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,321.09 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.59 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,298.11 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$6,671.93 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,488.58 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,042.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,930.61 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,474.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,894.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,559.95 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,488.58 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,301.27 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,474.50 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,445.59 ","$7,042.60 ",
MRI Brain w/ Contrast,70552,CDM,611,RC,70552,HCPCS,outpatient,,,"$1,740.00 ",$609.00 ,,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$609.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,339.80 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$539.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,566.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,653.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.30 ,"$1,653.00 ",
MRI Brain w/o Contrast,1168800,CDM,611,RC,70551,HCPCS,outpatient,,,"$2,798.51 ",$979.48 ,,"$1,500.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,500.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,238.81 ",80,,,percent of total billed charges,80% of total billed charges,$884.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$979.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$876.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,238.81 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,958.96 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,958.96 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,154.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$876.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$876.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$876.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$876.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$876.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$867.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,518.66 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$561.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,658.58 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,238.81 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$556.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,602.61 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,098.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$561.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,378.73 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$545.71 ,"$2,658.58 ",
MRI Chest w/ + w/o Contrast,1168820,CDM,614,RC,71552,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Chest w/o Contrast,1168824,CDM,614,RC,71550,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Elbow w/ + w/o Contrast Left,1168836,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Elbow w/ + w/o Contrast Right,1168838,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Elbow w/ Contrast Left,28355D,CDM,610,RC,73221,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Elbow w/ Contrast Right,28355,CDM,610,RC,73221,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Elbow w/o Contrast Left,1168848,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Elbow w/o Contrast Right,1168850,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Face Neck Orbit w/ + w/o Contrast,1168852,CDM,611,RC,70543,HCPCS,outpatient,,,"$2,000.00 ",$700.00 ,,"$1,072.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,072.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,600.00 ",80,,,percent of total billed charges,80% of total billed charges,$632.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$700.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,600.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,400.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,400.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,540.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$397.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$626.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$390.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$620.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,800.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$401.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,900.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,600.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$397.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,860.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,500.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$401.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,700.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$397.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$390.00 ,"$1,900.00 ",
MRI Face Neck Orbit w/o Contrast,1168856,CDM,610,RC,70540,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Femur w/ + w/o Contrast Left,73720,CDM,610,RC,73720,HCPCS,outpatient,,,"$5,093.00 ","$1,782.55 ",,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,782.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,921.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,578.83 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,583.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,838.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,736.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$993.14 ,"$4,838.35 ",
MRI Femur w/ Contrast Left,203103,CDM,610,RC,73719,HCPCS,outpatient,,,"$1,600.00 ",$560.00 ,,$857.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$857.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$560.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,120.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,232.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$496.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,440.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$321.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,520.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,488.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$321.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.00 ,"$1,520.00 ",
MRI Femur w/ Contrast Right,203104,CDM,610,RC,73719,HCPCS,outpatient,,,"$1,600.00 ",$560.00 ,,$857.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$857.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges,$505.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$560.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,120.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,232.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$496.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,440.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$321.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,520.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,488.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,200.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$321.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,360.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.00 ,"$1,520.00 ",
MRI Femur w/o Contrast Left,28356D,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,605.00 ",$561.75 ,,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$561.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,235.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$497.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,444.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,524.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,492.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.98 ,"$1,524.75 ",
MRI Femur w/o Contrast Right,28356D2,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,605.00 ",$561.75 ,,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$561.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,235.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$497.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,444.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,524.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,492.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.98 ,"$1,524.75 ",
MRI Foot w/ + w/o Contrast Left,28359D,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Foot w/ + w/o Contrast Right,28359,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Foot w/ Contrast Left,203105,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
MRI Foot w/ Contrast Right,203106,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
MRI Foot w/o Contrast Left,1168890,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Foot w/o Contrast Right,1168892,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Forearm w/ + w/o Contrast Left,73220,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Forearm w/ + w/o Contrast Left,8099909,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Forearm w/ + w/o Contrast Right,8099911,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Forearm w/ Contrast Left,30200D,CDM,610,RC,73219,HCPCS,outpatient,,,"$3,072.90 ","$1,075.52 ",,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,075.52 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,366.13 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$962.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$952.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,765.61 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,919.26 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,857.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$599.22 ,"$2,919.26 ",
MRI Forearm w/ Contrast Right,30200D2,CDM,610,RC,73219,HCPCS,outpatient,,,"$3,072.90 ","$1,075.52 ",,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,075.52 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,366.13 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$962.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$952.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,765.61 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,919.26 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,857.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$599.22 ,"$2,919.26 ",
MRI Forearm w/o Contrast Left,28352D,CDM,610,RC,73218,HCPCS,outpatient,,,"$1,993.00 ",$697.55 ,,"$1,068.25 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,068.25 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$697.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,395.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,534.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$388.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$617.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,793.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$400.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,893.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,853.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$400.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$388.64 ,"$1,893.35 ",
MRI Forearm w/o Contrast Right,28352,CDM,610,RC,73218,HCPCS,outpatient,,,"$1,993.00 ",$697.55 ,,"$1,068.25 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,068.25 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges,$630.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$697.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,395.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,534.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$624.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$388.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$617.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,793.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$400.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,893.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,594.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,853.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,494.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$400.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,694.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$388.64 ,"$1,893.35 ",
MRI Hand w/ + w/o Contrast Left,1168918,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Hand w/ + w/o Contrast Right,1168920,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Hand w/ Contrast Left,203107,CDM,610,RC,73222,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
MRI Hand w/ Contrast Right,203108,CDM,610,RC,73222,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
MRI Hand w/o Contrast Left,1168930,CDM,610,RC,73218,HCPCS,outpatient,,,$653.00 ,$228.55 ,,$350.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$350.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.40 ,80,,,percent of total billed charges,80% of total billed charges,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$228.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$522.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$457.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$457.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$502.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$202.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$587.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$131.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$620.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$607.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.34 ,$620.35 ,
MRI Hand w/o Contrast Right,1168932,CDM,610,RC,73218,HCPCS,outpatient,,,$653.00 ,$228.55 ,,$350.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$350.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$489.75 ,75,,,percent of total billed charges,75% of total billed charges,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.40 ,80,,,percent of total billed charges,80% of total billed charges,$206.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$228.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$522.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$457.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$457.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$502.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$202.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$587.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$131.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$620.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$607.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$555.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.34 ,$620.35 ,
MRI Hip w/ + w/o Contrast Left,1168936,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Hip w/ + w/o Contrast Right,1168938,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Hip w/ Contrast Left,203109,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,300.00 ",$455.00 ,,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$455.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,001.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$403.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,170.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,235.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,209.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$253.50 ,"$1,235.00 ",
MRI Hip w/ Contrast Right,203110,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,300.00 ",$455.00 ,,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$455.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,001.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$403.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,170.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,235.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,209.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$253.50 ,"$1,235.00 ",
MRI Hip w/o Contrast Left,1168948,CDM,610,RC,73721,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Hip w/o Contrast Right,1168950,CDM,610,RC,73721,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Humerus w/ + w/o Contrast Left,8099921,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Humerus w/ + w/o Contrast Right,8099923,CDM,610,RC,73220,HCPCS,outpatient,,,"$3,030.00 ","$1,060.50 ",,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,624.08 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges,$958.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,060.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,333.10 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$948.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$939.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,727.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,878.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,424.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,817.90 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,272.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$608.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,575.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.85 ,"$2,878.50 ",
MRI Humerus w/ Contrast Left,30200D3,CDM,610,RC,73219,HCPCS,outpatient,,,"$3,072.90 ","$1,075.52 ",,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,075.52 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,366.13 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$962.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$952.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,765.61 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,919.26 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,857.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$599.22 ,"$2,919.26 ",
MRI Humerus w/ Contrast Right,30200,CDM,610,RC,73219,HCPCS,outpatient,,,"$3,072.90 ","$1,075.52 ",,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,647.07 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges,$971.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,075.52 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,151.03 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,366.13 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$962.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$962.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$952.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,765.61 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,919.26 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,458.32 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,857.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,304.68 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,611.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$611.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$599.22 ,"$2,919.26 ",
MRI Humerus w/o Contrast Left,8099929,CDM,610,RC,73218,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Humerus w/o Contrast Right,8099931,CDM,610,RC,73218,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Knee w/ + w/o Contrast Left,1168972,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Knee w/ + w/o Contrast Right,1168974,CDM,610,RC,73723,HCPCS,outpatient,,,"$2,981.00 ","$1,043.35 ",,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,597.82 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges,$942.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,043.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,086.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,295.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$933.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$924.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,682.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,831.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,384.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,772.33 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,235.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$598.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,533.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$581.30 ,"$2,831.95 ",
MRI Knee w/ Contrast Left,203111,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,300.00 ",$455.00 ,,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$455.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,001.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$403.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,170.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,235.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,209.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$253.50 ,"$1,235.00 ",
MRI Knee w/ Contrast Right,203112,CDM,610,RC,73722,HCPCS,outpatient,,,"$1,300.00 ",$455.00 ,,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$696.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$975.00 ,75,,,percent of total billed charges,75% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges,$411.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$455.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$910.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,001.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$407.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$403.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,170.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,235.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,209.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$975.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$261.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,105.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$253.50 ,"$1,235.00 ",
MRI Knee w/o Contrast Left,1168984,CDM,610,RC,73721,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Knee w/o Contrast Right,1168986,CDM,610,RC,73721,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI MRCP,8099933,CDM,614,RC,74181,HCPCS,outpatient,,,"$1,605.00 ",$561.75 ,,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$561.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,235.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$497.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,444.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,524.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,492.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.98 ,"$1,524.75 ",
MRI Pelvis w/ + w/o Contrast,1169024,CDM,612,RC,72197,HCPCS,outpatient,,,"$5,859.00 ","$2,050.65 ",,"$3,140.42 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,140.42 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,687.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,852.62 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,050.65 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,687.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,101.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,101.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,511.43 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,165.36 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,834.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,142.51 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,816.29 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,273.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,176.49 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,566.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,687.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,165.36 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,448.87 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,394.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,176.49 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,980.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,165.36 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,142.51 ","$5,566.05 ",
MRI Pelvis w/ Contrast,203113,CDM,612,RC,72196,HCPCS,outpatient,,,"$1,400.00 ",$490.00 ,,$750.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$750.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges,$442.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$490.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$980.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$980.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,078.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$273.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$434.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,260.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$281.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,330.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,302.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,050.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,190.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$273.00 ,"$1,330.00 ",
MRI Pelvis w/o Contrast,1169028,CDM,612,RC,72195,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Renal w/ + w/o Contrast,8522974,CDM,614,RC,74183,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Shoulder w/ + w/o Contrast Left,1169032,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Shoulder w/ + w/o Contrast Right,1169034,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Shoulder w/o Contrast Left,1169044,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,696.00 ",$593.60 ,,$909.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$909.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$593.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,187.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,187.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,305.92 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$525.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,526.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$340.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,611.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,577.28 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$340.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$330.72 ,"$1,611.20 ",
MRI Shoulder w/o Contrast Right,1169046,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,696.00 ",$593.60 ,,$909.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$909.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges,$536.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$593.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,187.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,187.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,305.92 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$531.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$525.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,526.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$340.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,611.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,356.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,577.28 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,272.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$340.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,441.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$330.72 ,"$1,611.20 ",
MRI Spine Cervical w/ + w/o Contrast,1169050,CDM,612,RC,72156,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Spine Cervical w/ Contrast,1169052,CDM,612,RC,74142,HCPCS,outpatient,,,"$1,740.00 ",$609.00 ,,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$609.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,339.80 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$539.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,566.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,653.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.30 ,"$1,653.00 ",
MRI Spine Cervical w/o Contrast,1169054,CDM,612,RC,72141,HCPCS,outpatient,,,"$1,700.00 ",$595.00 ,,$911.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$911.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,360.00 ",80,,,percent of total billed charges,80% of total billed charges,$537.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$595.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,360.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,190.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,309.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$532.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$527.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,530.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$341.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,615.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,360.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$338.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,581.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,275.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$341.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,445.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$331.50 ,"$1,615.00 ",
MRI Spine Entire w/o Contrast,9716529,CDM,320,RC,72082,HCPCS,outpatient,,,$303.90 ,$106.37 ,,$162.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.93 ,75,,,percent of total billed charges,75% of total billed charges,$227.93 ,75,,,percent of total billed charges,75% of total billed charges,$227.93 ,75,,,percent of total billed charges,75% of total billed charges,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$243.12 ,80,,,percent of total billed charges,80% of total billed charges,$96.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$106.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$212.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$234.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$94.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$273.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$61.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$288.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$227.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.26 ,$288.71 ,
MRI Spine Lumbar w/o Contrast,72148,CDM,612,RC,72148,HCPCS,outpatient,,,"$5,227.02 ","$1,829.46 ",,"$2,801.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,801.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,829.46 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,658.91 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,658.91 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,024.81 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,019.27 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,620.38 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,704.32 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,049.59 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,965.67 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,861.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,049.59 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,019.27 ","$4,965.67 ",
MRI Spine Lumbar w/ + w/o Contrast,1169056,CDM,612,RC,72158,HCPCS,outpatient,,,"$3,168.00 ","$1,108.80 ",,"$1,698.05 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,698.05 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,001.72 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,108.80 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,217.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,217.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,439.36 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$991.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$982.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,851.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$636.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,009.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,534.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,946.24 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,376.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$636.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,692.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$630.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$617.76 ,"$3,009.60 ",
MRI Spine Lumbar w/ Contrast,203114,CDM,612,RC,72149,HCPCS,outpatient,,,"$4,200.00 ","$1,470.00 ",,"$2,251.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,251.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,360.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,328.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,470.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,360.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,940.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,940.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,234.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$835.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,315.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,302.00 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,780.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$843.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,990.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,360.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$835.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,906.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,150.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$843.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,570.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$835.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$819.00 ,"$3,990.00 ",
MRI Spine Lumbar w/o Contrast,72148,CDM,612,RC,72148,HCPCS,outpatient,,,"$5,227.02 ","$1,829.46 ",,"$2,801.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,801.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges,"$1,652.78 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,829.46 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,658.91 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,658.91 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,024.81 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,636.58 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,019.27 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,620.38 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,704.32 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,049.59 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,965.67 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,181.62 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,861.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,920.27 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,049.59 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,442.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,039.65 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,019.27 ","$4,965.67 ",
MRI Spine Thoracic w/ + w/o Contrast,1169062,CDM,612,RC,72157,HCPCS,outpatient,,,"$5,806.00 ","$2,032.10 ",,"$3,112.02 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,112.02 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,644.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,835.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,032.10 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,644.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,064.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,064.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,470.62 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.81 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,817.86 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,132.17 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,799.86 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,225.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,165.84 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,515.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,644.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,154.81 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,399.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,354.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,165.84 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,935.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.81 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,132.17 ","$5,515.70 ",
MRI Spine Thoracic w/ Contrast,1169064,CDM,612,RC,72147,HCPCS,outpatient,,,"$1,740.00 ",$609.00 ,,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$609.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,339.80 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$539.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,566.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,653.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.30 ,"$1,653.00 ",
MRI Spine Thoracic w/o Contrast,1169066,CDM,612,RC,72146,HCPCS,outpatient,,,"$4,095.00 ","$1,433.25 ",,"$2,194.92 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,194.92 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,294.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,433.25 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,866.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,866.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,153.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,282.14 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,269.45 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,685.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$822.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,890.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,808.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,071.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$822.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,480.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$798.53 ,"$3,890.25 ",
MRI TMJ,1169068,CDM,610,RC,70336,HCPCS,outpatient,,,"$1,740.00 ",$609.00 ,,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$932.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges,$550.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$609.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,218.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,339.80 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$539.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,566.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,653.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,392.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,618.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,305.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$349.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,479.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.30 ,"$1,653.00 ",
MRI Tibia/Fibula w/ + w/o Contrast Left,73720,CDM,610,RC,73720,HCPCS,outpatient,,,"$5,093.00 ","$1,782.55 ",,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,782.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,921.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,578.83 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,583.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,838.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,736.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$993.14 ,"$4,838.35 ",
MRI Tibia/Fibula w/ + w/o Contrast Right,73720,CDM,610,RC,73720,HCPCS,outpatient,,,"$5,093.00 ","$1,782.55 ",,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,729.85 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,610.41 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,782.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,565.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,921.61 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,594.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,578.83 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,583.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,838.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,074.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,736.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,819.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,022.67 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,329.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$993.14 ,"$4,838.35 ",
MRI Tibia/Fibula w/ Contrast Left,203115,CDM,610,RC,73719,HCPCS,outpatient,,,"$3,000.00 ","$1,050.00 ",,"$1,608.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,608.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,050.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,100.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,100.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,310.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$585.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$930.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,700.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$602.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,850.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,790.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$602.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$585.00 ,"$2,850.00 ",
MRI Tibia/Fibula w/ Contrast Right,203115,CDM,610,RC,73719,HCPCS,outpatient,,,"$3,000.00 ","$1,050.00 ",,"$1,608.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,608.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges,$948.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,050.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,100.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,100.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,310.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$939.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$585.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$930.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,700.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$602.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,850.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,400.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,790.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,250.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$602.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,550.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$596.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$585.00 ,"$2,850.00 ",
MRI Tibia/Fibula w/o Contrast Left,28356D3,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,605.00 ",$561.75 ,,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$561.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,235.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$497.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,444.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,524.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,492.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.98 ,"$1,524.75 ",
MRI Tibia/Fibula w/o Contrast Right,28356,CDM,610,RC,73718,HCPCS,outpatient,,,"$1,605.00 ",$561.75 ,,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$860.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges,$507.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$561.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,123.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,235.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$497.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,444.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,524.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,284.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,492.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,203.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$322.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,364.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.98 ,"$1,524.75 ",
MRI Wrist w/ + w/o Contrast Left,1169128,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Wrist w/ + w/o Contrast Right,1169130,CDM,610,RC,73223,HCPCS,outpatient,,,"$2,755.00 ",$964.25 ,,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,476.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges,$871.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$964.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,928.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,121.35 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$854.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,479.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,617.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,204.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,066.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$553.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,341.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.23 ,"$2,617.25 ",
MRI Wrist w/ Contrast Left,203116,CDM,610,RC,73222,HCPCS,outpatient,,,"$2,700.00 ",$945.00 ,,"$1,447.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,447.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$945.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,890.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,890.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,079.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$526.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$837.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,430.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$542.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,565.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,511.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$542.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$526.50 ,"$2,565.00 ",
MRI Wrist w/ Contrast Right,203116,CDM,610,RC,73222,HCPCS,outpatient,,,"$2,700.00 ",$945.00 ,,"$1,447.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,447.20 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$853.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$945.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,890.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,890.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,079.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$526.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$837.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,430.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$542.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,565.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,511.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,025.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$542.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,295.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$526.50 ,"$2,565.00 ",
MRI Wrist w/o Contrast Left,1169140,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
MRI Wrist w/o Contrast Right,1169142,CDM,610,RC,73221,HCPCS,outpatient,,,"$1,305.00 ",$456.75 ,,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$699.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$978.75 ,75,,,percent of total billed charges,75% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges,$412.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$456.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$913.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,004.85 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$404.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,174.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,239.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,044.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,213.65 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$978.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.48 ,"$1,239.75 ",
US AAA Screening,8111052,CDM,402,RC,76706,HCPCS,outpatient,,,$254.00 ,$88.90 ,,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$195.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$228.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$241.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.53 ,$241.30 ,
US ABI,8211178,CDM,921,RC,93922,HCPCS,outpatient,,,$508.00 ,$177.80 ,,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$272.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,75,,,percent of total billed charges,75% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges,$160.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$177.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$355.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$391.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$157.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$457.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$482.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$381.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$431.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.06 ,$482.60 ,
US ABI Complete Bilateral,28568,CDM,921,RC,93923,HCPCS,outpatient,,,$257.00 ,$89.95 ,,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$197.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$231.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$244.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.12 ,$244.15 ,
US Abdomen Complete,1169567,CDM,402,RC,76700,HCPCS,outpatient,,,"$1,450.00 ",$507.50 ,,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$777.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges,$458.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$507.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,015.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$454.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$449.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,305.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,377.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,348.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,087.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,232.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.75 ,"$1,377.50 ",
US Abdomen Limited,1169569,CDM,402,RC,76705,HCPCS,outpatient,,,$907.63 ,$317.67 ,,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$317.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$281.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$816.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$862.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.99 ,$862.25 ,
US Aorta,8211181,CDM,402,RC,76770,HCPCS,outpatient,,,$414.48 ,$145.07 ,,$222.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$222.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.58 ,80,,,percent of total billed charges,80% of total billed charges,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$145.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$331.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$290.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$290.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$319.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$128.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$373.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$393.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.82 ,$393.76 ,
US Aorta IVC Iliac Duplex Limited,1169579,CDM,402,RC,76775,HCPCS,outpatient,,,$886.00 ,$310.10 ,,$474.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$474.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$664.50 ,75,,,percent of total billed charges,75% of total billed charges,$664.50 ,75,,,percent of total billed charges,75% of total billed charges,$664.50 ,75,,,percent of total billed charges,75% of total billed charges,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$708.80 ,80,,,percent of total billed charges,80% of total billed charges,$280.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$310.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$708.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$620.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$620.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$682.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$274.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$797.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$177.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$841.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$708.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$176.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$823.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$664.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$664.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$664.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$753.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$172.77 ,$841.70 ,
US Appendix,2425293,CDM,402,RC,76705,HCPCS,outpatient,,,$907.63 ,$317.67 ,,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$317.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$281.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$816.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$862.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.99 ,$862.25 ,
US Art/Vein Abd/Pelvis/Scrotal Limited,1169583,CDM,921,RC,93976,HCPCS,outpatient,,,$766.00 ,$268.10 ,,$410.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$410.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$574.50 ,75,,,percent of total billed charges,75% of total billed charges,$574.50 ,75,,,percent of total billed charges,75% of total billed charges,$574.50 ,75,,,percent of total billed charges,75% of total billed charges,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$612.80 ,80,,,percent of total billed charges,80% of total billed charges,$242.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$536.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$689.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$153.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$727.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$712.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$574.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$574.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$574.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$651.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.37 ,$727.70 ,
US Bladder Scan,8100919,CDM,402,RC,76856,HCPCS,outpatient,,,$841.60 ,$294.56 ,,$451.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$451.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$673.28 ,80,,,percent of total billed charges,80% of total billed charges,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$294.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$673.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$589.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$648.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$263.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$260.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$757.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$168.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$799.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$673.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$782.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.11 ,$799.52 ,
US Breast Biopsy w/ Clip Left,8939637,CDM,402,RC,19285,HCPCS,outpatient,,,$779.00 ,$272.65 ,,$417.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$417.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$623.20 ,80,,,percent of total billed charges,80% of total billed charges,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$272.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$623.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$545.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$599.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$241.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$701.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$156.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$740.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$623.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$724.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$156.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.91 ,$740.05 ,
US Breast Biopsy w/ Clip Right,8939640,CDM,402,RC,19285,HCPCS,outpatient,,,$779.00 ,$272.65 ,,$417.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$417.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$584.25 ,75,,,percent of total billed charges,75% of total billed charges,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$623.20 ,80,,,percent of total billed charges,80% of total billed charges,$246.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$272.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$623.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$545.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$599.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$241.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$701.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$156.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$740.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$623.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$724.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$156.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$662.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.91 ,$740.05 ,
US Breast Complete Left,4645474,CDM,402,RC,76641,HCPCS,outpatient,,,$680.00 ,$238.00 ,,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$238.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$523.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$210.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$612.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$646.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$632.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.60 ,$646.00 ,
US Breast Complete Right,4645477,CDM,402,RC,76641,HCPCS,outpatient,,,$680.00 ,$238.00 ,,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$364.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$510.00 ,75,,,percent of total billed charges,75% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges,$215.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$238.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$476.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$523.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$210.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$612.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$646.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$544.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$632.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$510.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$578.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.60 ,$646.00 ,
US Breast Complete Bilat.,76645,CDM,402,RC,76645,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
US Breast Cyst Aspiration Left,2425311,CDM,402,RC,76942,HCPCS,outpatient,,,$399.00 ,$139.65 ,,$213.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.20 ,80,,,percent of total billed charges,80% of total billed charges,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$279.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$307.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$359.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$379.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$371.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.81 ,$379.05 ,
US Breast Cyst Aspiration Right,2425314,CDM,402,RC,76942,HCPCS,outpatient,,,$399.00 ,$139.65 ,,$213.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$299.25 ,75,,,percent of total billed charges,75% of total billed charges,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.20 ,80,,,percent of total billed charges,80% of total billed charges,$126.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$279.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$307.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$359.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$379.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$371.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$339.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.81 ,$379.05 ,
US Breast Limited Left,4036646,CDM,402,RC,76642,HCPCS,outpatient,,,"$1,019.91 ",$356.97 ,,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$356.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$785.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$316.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$917.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$968.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.88 ,$968.91 ,
US Breast Limited Right,4645483,CDM,402,RC,76642,HCPCS,outpatient,,,"$1,019.91 ",$356.97 ,,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$546.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$764.93 ,75,,,percent of total billed charges,75% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges,$322.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$356.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$713.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$785.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$316.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$917.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$968.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$815.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$948.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$764.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$866.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.88 ,$968.91 ,
US Carotid Duplex Bilateral,1169631,CDM,921,RC,93880,HCPCS,outpatient,,,"$1,168.31 ",$408.91 ,,$626.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$626.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$876.23 ,75,,,percent of total billed charges,75% of total billed charges,$876.23 ,75,,,percent of total billed charges,75% of total billed charges,$876.23 ,75,,,percent of total billed charges,75% of total billed charges,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$934.65 ,80,,,percent of total billed charges,80% of total billed charges,$369.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$408.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$934.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$817.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$817.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$899.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$365.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$362.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,051.48 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$234.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,109.89 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$934.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$232.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,086.53 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$876.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$876.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$876.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$234.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$993.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$227.82 ,"$1,109.89 ",
US Chest,1169635,CDM,402,RC,76604,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
US Echo 2D Complete,20016,CDM,483,RC,93306,HCPCS,outpatient,,,"$3,943.84 ","$1,380.34 ",,"$2,113.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,113.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,155.07 ",80,,,percent of total billed charges,80% of total billed charges,"$1,247.04 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,380.34 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,155.07 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,760.69 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,760.69 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,036.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,234.82 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,222.59 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,549.46 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$791.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,746.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,155.07 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$784.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,667.77 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,957.88 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$791.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,352.26 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$769.05 ,"$3,746.65 ",
US Extremity Nonvascular Limited Right,76882,CDM,402,RC,76882,HCPCS,outpatient,,,$424.00 ,$148.40 ,,$227.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$318.00 ,75,,,percent of total billed charges,75% of total billed charges,$318.00 ,75,,,percent of total billed charges,75% of total billed charges,$318.00 ,75,,,percent of total billed charges,75% of total billed charges,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$339.20 ,80,,,percent of total billed charges,80% of total billed charges,$134.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$148.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$296.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$326.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$131.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$381.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$402.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$394.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$318.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$360.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.68 ,$402.80 ,
US Extremity Nonvascular Complete Left,2425332,CDM,402,RC,76881,HCPCS,outpatient,,,$663.00 ,$232.05 ,,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$232.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$510.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$205.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$596.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$629.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$616.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.29 ,$629.85 ,
US Extremity Nonvascular Complete Right,2425335,CDM,402,RC,76881,HCPCS,outpatient,,,$663.00 ,$232.05 ,,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$232.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$510.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$205.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$596.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$629.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$616.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.29 ,$629.85 ,
US Extremity Nonvascular Limited Left,2425338,CDM,402,RC,76882,HCPCS,outpatient,,,$431.00 ,$150.85 ,,$231.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$231.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.80 ,80,,,percent of total billed charges,80% of total billed charges,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$150.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$344.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$301.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$133.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$387.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$86.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$409.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$344.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.05 ,$409.45 ,
US Extremity Nonvascular Limited Right,2425341,CDM,402,RC,76882,HCPCS,outpatient,,,$431.00 ,$150.85 ,,$231.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$231.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$323.25 ,75,,,percent of total billed charges,75% of total billed charges,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.80 ,80,,,percent of total billed charges,80% of total billed charges,$136.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$150.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$344.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$301.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$134.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$133.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$387.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$86.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$409.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$344.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$323.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$366.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.05 ,$409.45 ,
US Fetal Biophysical Profile w/ Non-Str,20034,CDM,402,RC,76818,HCPCS,outpatient,,,$727.00 ,$254.45 ,,$389.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$389.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$545.25 ,75,,,percent of total billed charges,75% of total billed charges,$545.25 ,75,,,percent of total billed charges,75% of total billed charges,$545.25 ,75,,,percent of total billed charges,75% of total billed charges,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$581.60 ,80,,,percent of total billed charges,80% of total billed charges,$229.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$254.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$581.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$508.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$559.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$225.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$654.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$145.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$690.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$581.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$676.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$545.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$545.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$545.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$145.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$617.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.77 ,$690.65 ,
US Fine Needle Aspiration Thyroid Gland,2425344,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,139.00 ",$398.65 ,,$610.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$610.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$911.20 ,80,,,percent of total billed charges,80% of total billed charges,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$398.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$911.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$797.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$797.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$877.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$353.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,025.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$228.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,082.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$911.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$228.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$222.11 ,"$1,082.05 ",
US Fine Needle Asp w/ Guide Each Add Les,9042560,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,139.00 ",$398.65 ,,$610.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$610.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$854.25 ,75,,,percent of total billed charges,75% of total billed charges,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$911.20 ,80,,,percent of total billed charges,80% of total billed charges,$360.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$398.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$911.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$797.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$797.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$877.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$356.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$353.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,025.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$228.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,082.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$911.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$854.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$228.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$968.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$222.11 ,"$1,082.05 ",
US Guided Breast Biopsy Right.,28391,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,220.00 ",$427.00 ,,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$939.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.90 ,"$1,159.00 ",
US Guided Breast Biopsy Left.,8033282,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,220.00 ",$427.00 ,,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$939.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.90 ,"$1,159.00 ",
US Guided Breast Biopsy Right,28391,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,220.00 ",$427.00 ,,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$939.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.90 ,"$1,159.00 ",
US Guided Breast Biopsy Right,28391,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,220.00 ",$427.00 ,,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$915.00 ,75,,,percent of total billed charges,75% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges,$385.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$427.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$854.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$939.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$378.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,098.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,159.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$976.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,134.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$915.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,037.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$237.90 ,"$1,159.00 ",
US Guided Vascular Access,76937,CDM,402,RC,76937,HCPCS,outpatient,,,$876.00 ,$306.60 ,,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$306.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$674.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$271.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$788.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$832.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.82 ,$832.20 ,
US Guided Vascular Access,2425350,CDM,402,RC,76937,HCPCS,outpatient,,,$876.00 ,$306.60 ,,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$306.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$674.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$271.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$788.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$832.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.82 ,$832.20 ,
US Guided Vascular Access,76937,CDM,402,RC,76937,HCPCS,outpatient,,,$876.00 ,$306.60 ,,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$306.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$674.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$271.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$788.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$832.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.82 ,$832.20 ,
US Guided Vascular Access EO,2425350,CDM,402,RC,76937,HCPCS,outpatient,,,$876.00 ,$306.60 ,,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$306.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$674.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$271.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$788.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$832.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.82 ,$832.20 ,
US Head/Neck Soft Tissue,1169729,CDM,402,RC,76536,HCPCS,outpatient,,,"$1,212.52 ",$424.38 ,,$649.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$649.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$970.02 ,80,,,percent of total billed charges,80% of total billed charges,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$424.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$970.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$848.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$933.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$375.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,091.27 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$243.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,151.89 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$970.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,127.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$236.44 ,"$1,151.89 ",
US Intraoperative,28291,CDM,320,RC,76998,HCPCS,outpatient,,,$255.00 ,$89.25 ,,$136.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$191.25 ,75,,,percent of total billed charges,75% of total billed charges,$191.25 ,75,,,percent of total billed charges,75% of total billed charges,$191.25 ,75,,,percent of total billed charges,75% of total billed charges,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$204.00 ,80,,,percent of total billed charges,80% of total billed charges,$80.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$229.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$242.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$191.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$191.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$191.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$216.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.73 ,$242.25 ,
US Liver (Hepatic),8112306,CDM,402,RC,76705,HCPCS,outpatient,,,$907.63 ,$317.67 ,,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$317.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$281.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$816.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$862.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.99 ,$862.25 ,
US Lower Ext Arterial Duplex Bilateral,1169759,CDM,921,RC,93925,HCPCS,outpatient,,,"$1,498.00 ",$524.30 ,,$802.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$802.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.40 ",80,,,percent of total billed charges,80% of total billed charges,$473.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$524.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,198.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,048.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,048.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,153.46 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$464.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,348.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$300.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,423.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,198.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,393.14 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,123.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$300.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,273.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$292.11 ,"$1,423.10 ",
US Lower Ext Arterial Duplex Left,1169761,CDM,921,RC,93926,HCPCS,outpatient,,,"$1,080.00 ",$378.00 ,,$578.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$578.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$864.00 ,80,,,percent of total billed charges,80% of total billed charges,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$378.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$756.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$756.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$831.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$334.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$972.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$216.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,026.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,004.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$210.60 ,"$1,026.00 ",
US Lower Ext Arterial Duplex Right,1169763,CDM,921,RC,93926,HCPCS,outpatient,,,"$1,080.00 ",$378.00 ,,$578.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$578.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$810.00 ,75,,,percent of total billed charges,75% of total billed charges,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$864.00 ,80,,,percent of total billed charges,80% of total billed charges,$341.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$378.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$864.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$756.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$756.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$831.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$334.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$972.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$216.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,026.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$864.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,004.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$810.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$918.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$210.60 ,"$1,026.00 ",
US Lower Ext Venous Duplex Bilateral,1169769,CDM,320,RC,93970,HCPCS,outpatient,,,$635.00 ,$222.25 ,,$340.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$340.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$508.00 ,80,,,percent of total billed charges,80% of total billed charges,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$222.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$444.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$444.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$488.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$196.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$571.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$127.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$603.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.83 ,$603.25 ,
US Lower Ext Venous Duplex Left,20024,CDM,921,RC,93970,HCPCS,outpatient,,,$749.93 ,$262.48 ,,$401.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$401.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$562.45 ,75,,,percent of total billed charges,75% of total billed charges,$562.45 ,75,,,percent of total billed charges,75% of total billed charges,$562.45 ,75,,,percent of total billed charges,75% of total billed charges,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$599.94 ,80,,,percent of total billed charges,80% of total billed charges,$237.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$262.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$599.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$524.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$577.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$234.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$232.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$674.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$150.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$712.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$149.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$562.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$562.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$562.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$637.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$146.24 ,$712.43 ,
US Lower Ext Venous Duplex Right,28079,CDM,921,RC,93971,HCPCS,outpatient,,,$231.66 ,$81.08 ,,$124.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.33 ,80,,,percent of total billed charges,80% of total billed charges,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.17 ,$220.08 ,
US Lower Ext Venous Reflux Bilateral,8127570,CDM,402,RC,93970,HCPCS,outpatient,,,"$1,015.00 ",$355.25 ,,$544.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$544.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$761.25 ,75,,,percent of total billed charges,75% of total billed charges,$761.25 ,75,,,percent of total billed charges,75% of total billed charges,$761.25 ,75,,,percent of total billed charges,75% of total billed charges,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$812.00 ,80,,,percent of total billed charges,80% of total billed charges,$320.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$355.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$812.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$710.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$710.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$781.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$317.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$314.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$913.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$203.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$964.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$201.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$943.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$761.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$761.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$761.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$203.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$862.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$197.93 ,$964.25 ,
US OB < 14 Weeks Multi,28077,CDM,320,RC,76802,HCPCS,outpatient,,,$443.00 ,$155.05 ,,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$155.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$341.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$137.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$398.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$420.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.39 ,$420.85 ,
US OB < 14 Weeks Single,8100928,CDM,320,RC,76801,HCPCS,outpatient,,,$443.00 ,$155.05 ,,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$155.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$341.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$137.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$398.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$420.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.39 ,$420.85 ,
US OB Greater Than 14 Weeks Ea Addl Gest,8894749,CDM,402,RC,76810,HCPCS,outpatient,,,$321.00 ,$112.35 ,,$172.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$240.75 ,75,,,percent of total billed charges,75% of total billed charges,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$256.80 ,80,,,percent of total billed charges,80% of total billed charges,$101.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$112.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$224.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$99.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$288.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$64.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$304.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$272.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.60 ,$304.95 ,
US OB Greater Than 14 Weeks Single,8992883,CDM,402,RC,76805,HCPCS,outpatient,,,$481.00 ,$168.35 ,,$257.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.75 ,75,,,percent of total billed charges,75% of total billed charges,$360.75 ,75,,,percent of total billed charges,75% of total billed charges,$360.75 ,75,,,percent of total billed charges,75% of total billed charges,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.80 ,80,,,percent of total billed charges,80% of total billed charges,$152.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$370.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$149.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.80 ,$456.95 ,
US OB Limited,1169856,CDM,402,RC,76815,HCPCS,outpatient,,,$802.00 ,$280.70 ,,$429.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$429.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$601.50 ,75,,,percent of total billed charges,75% of total billed charges,$601.50 ,75,,,percent of total billed charges,75% of total billed charges,$601.50 ,75,,,percent of total billed charges,75% of total billed charges,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$641.60 ,80,,,percent of total billed charges,80% of total billed charges,$253.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$280.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$641.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$561.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$617.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$251.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$248.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$721.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$161.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$761.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$641.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$745.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$601.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$601.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$601.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$161.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$681.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.39 ,$761.90 ,
US OB Nuchal Measure 1st Trimester,1169858,CDM,320,RC,76813,HCPCS,outpatient,,,$443.00 ,$155.05 ,,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$332.25 ,75,,,percent of total billed charges,75% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges,$140.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$155.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$310.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$341.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$137.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$398.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$420.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$332.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$88.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$376.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.39 ,$420.85 ,
US OB Transvaginal,1169861,CDM,320,RC,76817,HCPCS,outpatient,,,$359.00 ,$125.65 ,,$192.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$269.25 ,75,,,percent of total billed charges,75% of total billed charges,$269.25 ,75,,,percent of total billed charges,75% of total billed charges,$269.25 ,75,,,percent of total billed charges,75% of total billed charges,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$287.20 ,80,,,percent of total billed charges,80% of total billed charges,$113.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$125.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$287.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$251.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$251.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$276.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$323.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$341.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$287.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$333.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$269.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$269.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$269.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$305.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.01 ,$341.05 ,
US Paracentesis,1169838,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,247.00 ",$436.45 ,,$668.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$668.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$997.60 ,80,,,percent of total billed charges,80% of total billed charges,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$436.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$997.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$872.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$872.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$960.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$386.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,122.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$250.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,184.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$997.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,159.71 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$250.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.17 ,"$1,184.65 ",
US Paracentesis EO,1169838,CDM,402,RC,76942,HCPCS,outpatient,,,"$1,247.00 ",$436.45 ,,$668.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$668.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$935.25 ,75,,,percent of total billed charges,75% of total billed charges,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$997.60 ,80,,,percent of total billed charges,80% of total billed charges,$394.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$436.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$997.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$872.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$872.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$960.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$390.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$386.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,122.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$250.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,184.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$997.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,159.71 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$935.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$250.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,059.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.17 ,"$1,184.65 ",
US Parathyroid,9042572,CDM,402,RC,76536,HCPCS,outpatient,,,$295.00 ,$103.25 ,,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$103.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$265.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.53 ,$280.25 ,
US Pelvic Complete,8102137,CDM,402,RC,76856,HCPCS,outpatient,,,$841.60 ,$294.56 ,,$451.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$451.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$631.20 ,75,,,percent of total billed charges,75% of total billed charges,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$673.28 ,80,,,percent of total billed charges,80% of total billed charges,$266.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$294.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$673.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$589.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$648.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$263.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$260.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$757.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$168.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$799.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$673.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$782.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$631.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$715.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.11 ,$799.52 ,
US Pelvic Ltd,8100934,CDM,402,RC,76857,HCPCS,outpatient,,,$339.00 ,$118.65 ,,$181.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$181.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.20 ,80,,,percent of total billed charges,80% of total billed charges,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$118.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$271.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$237.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$261.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$105.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$305.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$68.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$322.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.11 ,$322.05 ,
US Renal Artery Duplex Bilateral,8420279,CDM,402,RC,93975,HCPCS,outpatient,,,$89.00 ,$31.15 ,,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.36 ,$84.55 ,
US Renal Bilateral,8939652,CDM,402,RC,76770,HCPCS,outpatient,,,$414.48 ,$145.07 ,,$222.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$222.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$310.86 ,75,,,percent of total billed charges,75% of total billed charges,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.58 ,80,,,percent of total billed charges,80% of total billed charges,$131.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$145.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$331.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$290.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$290.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$319.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$128.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$373.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$393.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$310.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$352.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.82 ,$393.76 ,
US Scrotum (Contents),8100937,CDM,402,RC,76870,HCPCS,outpatient,,,"$1,399.38 ",$489.78 ,,$750.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$750.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,119.50 ",80,,,percent of total billed charges,80% of total billed charges,$442.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$489.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,119.50 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$979.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$979.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,077.52 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$438.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$433.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,259.44 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$281.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,329.41 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,119.50 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,301.42 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,049.54 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,189.47 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$272.88 ,"$1,329.41 ",
US Soft Tissue,8100940,CDM,402,RC,76705,HCPCS,outpatient,,,$907.63 ,$317.67 ,,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$486.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$680.72 ,75,,,percent of total billed charges,75% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges,$286.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$317.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$635.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$281.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$816.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$862.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$726.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$844.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$680.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$771.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.99 ,$862.25 ,
US Spinal Canal,1169879,CDM,402,RC,76800,HCPCS,outpatient,,,$453.00 ,$158.55 ,,$242.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$242.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$339.75 ,75,,,percent of total billed charges,75% of total billed charges,$339.75 ,75,,,percent of total billed charges,75% of total billed charges,$339.75 ,75,,,percent of total billed charges,75% of total billed charges,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$362.40 ,80,,,percent of total billed charges,80% of total billed charges,$143.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$158.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$362.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$317.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$348.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$140.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$407.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$430.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$421.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$339.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$385.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.34 ,$430.35 ,
US Spleen,8106649,CDM,402,RC,76705,HCPCS,outpatient,,,$473.00 ,$165.55 ,,$253.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$253.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$354.75 ,75,,,percent of total billed charges,75% of total billed charges,$354.75 ,75,,,percent of total billed charges,75% of total billed charges,$354.75 ,75,,,percent of total billed charges,75% of total billed charges,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.40 ,80,,,percent of total billed charges,80% of total billed charges,$149.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$165.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$425.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$94.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$449.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$354.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$354.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$354.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$402.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.24 ,$449.35 ,
US Thoracentesis,1169881,CDM,402,RC,76937,HCPCS,outpatient,,,$876.00 ,$306.60 ,,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$657.00 ,75,,,percent of total billed charges,75% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges,$276.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$306.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$613.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$674.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$271.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$788.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$832.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$700.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$814.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$657.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$744.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.82 ,$832.20 ,
US Thyroid,8099960,CDM,402,RC,76536,HCPCS,outpatient,,,"$1,212.52 ",$424.38 ,,$649.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$649.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$909.39 ,75,,,percent of total billed charges,75% of total billed charges,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$970.02 ,80,,,percent of total billed charges,80% of total billed charges,$383.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$424.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$970.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$848.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$933.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$379.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$375.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,091.27 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$243.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,151.89 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$970.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,127.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$909.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,030.64 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$236.44 ,"$1,151.89 ",
US Transvaginal Non-OB,1169889,CDM,402,RC,76830,HCPCS,outpatient,,,$995.00 ,$348.25 ,,$533.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$533.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$746.25 ,75,,,percent of total billed charges,75% of total billed charges,$746.25 ,75,,,percent of total billed charges,75% of total billed charges,$746.25 ,75,,,percent of total billed charges,75% of total billed charges,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$796.00 ,80,,,percent of total billed charges,80% of total billed charges,$314.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$348.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$796.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$696.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$766.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$308.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$895.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$199.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$945.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$796.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$746.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$746.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$746.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$845.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$194.03 ,$945.25 ,
US Upper Ext Arterial Duplex Bilateral,1169895,CDM,921,RC,93930,HCPCS,outpatient,,,$765.00 ,$267.75 ,,$410.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$410.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$573.75 ,75,,,percent of total billed charges,75% of total billed charges,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$612.00 ,80,,,percent of total billed charges,80% of total billed charges,$241.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$267.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$535.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$535.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$688.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$153.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$726.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$573.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$650.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.18 ,$726.75 ,
US Upper Ext Arterial Duplex Left,1169897,CDM,921,RC,93931,HCPCS,outpatient,,,$598.00 ,$209.30 ,,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$209.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$460.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$185.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$538.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$568.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$116.61 ,$568.10 ,
US Upper Ext Arterial Duplex Right,1169899,CDM,921,RC,93931,HCPCS,outpatient,,,$598.00 ,$209.30 ,,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$209.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$460.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$185.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$538.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$568.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$116.61 ,$568.10 ,
US Upper Ext Venous Duplex Bilateral,1169901,CDM,320,RC,93970,HCPCS,outpatient,,,$635.00 ,$222.25 ,,$340.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$340.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$476.25 ,75,,,percent of total billed charges,75% of total billed charges,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$508.00 ,80,,,percent of total billed charges,80% of total billed charges,$200.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$222.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$444.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$444.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$488.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$196.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$571.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$127.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$603.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$476.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$539.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.83 ,$603.25 ,
US Upper Ext Venous Duplex Left,28510,CDM,921,RC,93971,HCPCS,outpatient,,,$767.00 ,$268.45 ,,$411.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$575.25 ,75,,,percent of total billed charges,75% of total billed charges,$575.25 ,75,,,percent of total billed charges,75% of total billed charges,$575.25 ,75,,,percent of total billed charges,75% of total billed charges,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$613.60 ,80,,,percent of total billed charges,80% of total billed charges,$242.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$613.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$536.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$590.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$690.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$154.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$728.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$613.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$713.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$575.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$575.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$651.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.57 ,$728.65 ,
US Upper Ext Venous Duplex Right,28510,CDM,921,RC,93971,HCPCS,outpatient,,,$231.66 ,$81.08 ,,$124.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$173.75 ,75,,,percent of total billed charges,75% of total billed charges,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.33 ,80,,,percent of total billed charges,80% of total billed charges,$73.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.17 ,$220.08 ,
US Vascular Guidance,20349,CDM,270,RC,79637,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
XR AC Joints Bilateral,1169922,CDM,320,RC,73050,HCPCS,outpatient,,,$139.00 ,$48.65 ,,$74.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$104.25 ,75,,,percent of total billed charges,75% of total billed charges,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.20 ,80,,,percent of total billed charges,80% of total billed charges,$43.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$125.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.11 ,$132.05 ,
XR Abdomen 1 View,8111091,CDM,320,RC,74018,HCPCS,outpatient,,,$331.58 ,$116.05 ,,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$102.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$298.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$308.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.66 ,$315.00 ,
XR Abdomen 2 Views,18009,CDM,320,RC,74019,HCPCS,outpatient,,,$234.00 ,$81.90 ,,$125.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$125.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$175.50 ,75,,,percent of total billed charges,75% of total billed charges,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$187.20 ,80,,,percent of total billed charges,80% of total billed charges,$73.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$180.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$72.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$210.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$222.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$175.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$198.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.63 ,$222.30 ,
XR Abdomen Complete w Decub and/or Erect,1169930,CDM,320,RC,74019,HCPCS,outpatient,,,"$1,368.00 ",$478.80 ,,$733.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$733.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,094.40 ",80,,,percent of total billed charges,80% of total billed charges,$432.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$478.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,094.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$957.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$957.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,053.36 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$428.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$424.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,231.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,299.60 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,094.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$272.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,272.24 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,026.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,162.80 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.76 ,"$1,299.60 ",
XR Abdomen KUB 1 View,1169926,CDM,320,RC,74018,HCPCS,outpatient,,,$117.00 ,$40.95 ,,$62.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$87.75 ,75,,,percent of total billed charges,75% of total billed charges,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.60 ,80,,,percent of total billed charges,80% of total billed charges,$37.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$105.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.82 ,$111.15 ,
XR Abdomen Series + Chest 1 View,1169932,CDM,320,RC,74022,HCPCS,outpatient,,,$245.88 ,$86.06 ,,$131.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$184.41 ,75,,,percent of total billed charges,75% of total billed charges,$184.41 ,75,,,percent of total billed charges,75% of total billed charges,$184.41 ,75,,,percent of total billed charges,75% of total billed charges,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.70 ,80,,,percent of total billed charges,80% of total billed charges,$77.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$221.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$233.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$184.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$184.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$184.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.95 ,$233.59 ,
XR Ankle 2 Views Left,1169936,CDM,320,RC,73600,HCPCS,outpatient,,,$243.00 ,$85.05 ,,$130.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.40 ,80,,,percent of total billed charges,80% of total billed charges,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$85.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$187.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$75.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$218.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$230.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.39 ,$230.85 ,
XR Ankle 2 Views Right,1169938,CDM,320,RC,73600,HCPCS,outpatient,,,$243.00 ,$85.05 ,,$130.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$182.25 ,75,,,percent of total billed charges,75% of total billed charges,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.40 ,80,,,percent of total billed charges,80% of total billed charges,$76.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$85.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$187.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$75.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$218.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$230.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.39 ,$230.85 ,
XR Ankle Complete 3+ Views Left,28368,CDM,320,RC,73610,HCPCS,outpatient,,,$449.60 ,$157.36 ,,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.67 ,$427.12 ,
XR Ankle Complete 3+ Views Bilateral,1169940,CDM,320,RC,73610,HCPCS,outpatient,,,$449.60 ,$157.36 ,,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.67 ,$427.12 ,
XR Ankle Complete 3+ Views Left,1169942,CDM,320,RC,73610,HCPCS,outpatient,,,$449.60 ,$157.36 ,,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.67 ,$427.12 ,
XR Ankle Complete 3+ Views Right,1169944,CDM,320,RC,73610,HCPCS,outpatient,,,$449.60 ,$157.36 ,,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$337.20 ,75,,,percent of total billed charges,75% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges,$142.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.67 ,$427.12 ,
XR Barium Enema w/ Air Complete,1170006,CDM,320,RC,74283,HCPCS,outpatient,,,$532.00 ,$186.20 ,,$285.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$285.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$399.00 ,75,,,percent of total billed charges,75% of total billed charges,$399.00 ,75,,,percent of total billed charges,75% of total billed charges,$399.00 ,75,,,percent of total billed charges,75% of total billed charges,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$425.60 ,80,,,percent of total billed charges,80% of total billed charges,$168.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$186.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$372.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$409.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$164.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$478.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$106.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$505.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$494.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$399.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$399.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$399.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$452.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.74 ,$505.40 ,
XR Bone Age Studies,1170014,CDM,320,RC,77072,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
XR Bone Age Studies Infant,8102140,CDM,320,RC,77076,HCPCS,outpatient,,,$471.00 ,$164.85 ,,$252.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$252.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$353.25 ,75,,,percent of total billed charges,75% of total billed charges,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.80 ,80,,,percent of total billed charges,80% of total billed charges,$148.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$164.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$376.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$329.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$329.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$362.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$423.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$94.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$447.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$376.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$353.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$400.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.85 ,$447.45 ,
XR Bone Length Study,8415001,CDM,320,RC,77073,HCPCS,outpatient,,,$339.00 ,$118.65 ,,$181.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$181.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$254.25 ,75,,,percent of total billed charges,75% of total billed charges,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.20 ,80,,,percent of total billed charges,80% of total billed charges,$107.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$118.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$271.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$237.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$237.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$261.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$105.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$305.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$68.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$322.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$288.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.11 ,$322.05 ,
XR Bone Survey (Metastatic),8211292,CDM,320,RC,77074,HCPCS,outpatient,,,$870.00 ,$304.50 ,,$466.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$466.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$652.50 ,75,,,percent of total billed charges,75% of total billed charges,$652.50 ,75,,,percent of total billed charges,75% of total billed charges,$652.50 ,75,,,percent of total billed charges,75% of total billed charges,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$696.00 ,80,,,percent of total billed charges,80% of total billed charges,$275.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$304.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$696.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$609.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$609.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$669.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$269.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$783.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$174.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$826.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$173.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$809.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$652.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$739.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.65 ,$826.50 ,
XR Calcaneus Left,1170032,CDM,320,RC,73650,HCPCS,outpatient,,,$309.00 ,$108.15 ,,$165.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$231.75 ,75,,,percent of total billed charges,75% of total billed charges,$231.75 ,75,,,percent of total billed charges,75% of total billed charges,$231.75 ,75,,,percent of total billed charges,75% of total billed charges,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$247.20 ,80,,,percent of total billed charges,80% of total billed charges,$97.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$108.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$247.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$237.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$95.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$278.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$62.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$293.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$287.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$231.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$231.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$231.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$262.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.26 ,$293.55 ,
XR Calcaneus Right,1170034,CDM,320,RC,73650,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
XR Calcaneus min 2 views,1170030,CDM,320,RC,73560,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$51.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.72 ,$91.20 ,
XR Chest 1 View,8102143,CDM,324,RC,71045,HCPCS,outpatient,,,$86.88 ,$30.41 ,,$46.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$65.16 ,75,,,percent of total billed charges,75% of total billed charges,$65.16 ,75,,,percent of total billed charges,75% of total billed charges,$65.16 ,75,,,percent of total billed charges,75% of total billed charges,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.50 ,80,,,percent of total billed charges,80% of total billed charges,$27.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$78.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$65.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.94 ,$82.54 ,
XR Chest 2 Views,689607,CDM,324,RC,71046,HCPCS,outpatient,,,$315.00 ,$110.25 ,,$168.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$236.25 ,75,,,percent of total billed charges,75% of total billed charges,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$252.00 ,80,,,percent of total billed charges,80% of total billed charges,$99.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$220.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$242.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$97.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$283.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$299.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$236.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$267.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.43 ,$299.25 ,
XR Chest 4+ Views,1170053,CDM,324,RC,71010,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
XR Chest Decubitus,1170049,CDM,324,RC,71046,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
XR Cholangiogram Injection Procedure,2425440,CDM,320,RC,47532  ,HCPCS,outpatient,,,$252.90 ,$88.52 ,,$135.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.68 ,75,,,percent of total billed charges,75% of total billed charges,$189.68 ,75,,,percent of total billed charges,75% of total billed charges,$189.68 ,75,,,percent of total billed charges,75% of total billed charges,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$202.32 ,80,,,percent of total billed charges,80% of total billed charges,$79.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$202.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$194.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$227.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$240.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$189.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$214.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.32 ,$240.26 ,
XR Cholangiogram in OR,1170065,CDM,320,RC,74300,HCPCS,outpatient,,,$231.00 ,$80.85 ,,$123.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.25 ,75,,,percent of total billed charges,75% of total billed charges,$173.25 ,75,,,percent of total billed charges,75% of total billed charges,$173.25 ,75,,,percent of total billed charges,75% of total billed charges,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.80 ,80,,,percent of total billed charges,80% of total billed charges,$73.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$207.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$219.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.05 ,$219.45 ,
XR Cholecystogram,8426454,CDM,320,RC,74290,HCPCS,outpatient,,,$291.90 ,$102.17 ,,$156.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$156.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.93 ,75,,,percent of total billed charges,75% of total billed charges,$218.93 ,75,,,percent of total billed charges,75% of total billed charges,$218.93 ,75,,,percent of total billed charges,75% of total billed charges,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$233.52 ,80,,,percent of total billed charges,80% of total billed charges,$92.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$102.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$233.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$204.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$224.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$90.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$262.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$218.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$248.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.92 ,$277.31 ,
XR Clavicle Bilat,8211690,CDM,320,RC,73000,HCPCS,outpatient,,,$96.00 ,$33.60 ,,$51.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$72.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.80 ,80,,,percent of total billed charges,80% of total billed charges,$30.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.72 ,$91.20 ,
XR Clavicle Left,1170075,CDM,320,RC,73000,HCPCS,outpatient,,,$478.00 ,$167.30 ,,$256.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$256.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$382.40 ,80,,,percent of total billed charges,80% of total billed charges,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$167.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$368.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$430.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$454.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$444.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.21 ,$454.10 ,
XR Clavicle Right,1170077,CDM,320,RC,73000,HCPCS,outpatient,,,$478.00 ,$167.30 ,,$256.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$256.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.50 ,75,,,percent of total billed charges,75% of total billed charges,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$382.40 ,80,,,percent of total billed charges,80% of total billed charges,$151.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$167.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$368.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$430.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$454.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$444.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$358.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$406.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.21 ,$454.10 ,
XR Elbow 2 Views Bilateral,1170119,CDM,320,RC,73070,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
XR Elbow 2 Views Left,1170121,CDM,320,RC,73070,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
XR Elbow 2 Views Right,1170123,CDM,320,RC,73070,HCPCS,outpatient,,,$450.00 ,$157.50 ,,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$241.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$337.50 ,75,,,percent of total billed charges,75% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges,$142.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$346.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$405.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$427.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$360.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$337.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$382.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.75 ,$427.50 ,
XR Elbow Complete 3+ Views Bilateral,1170125,CDM,320,RC,73080,HCPCS,outpatient,,,$116.00 ,$40.60 ,,$62.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.00 ,75,,,percent of total billed charges,75% of total billed charges,$87.00 ,75,,,percent of total billed charges,75% of total billed charges,$87.00 ,75,,,percent of total billed charges,75% of total billed charges,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,80,,,percent of total billed charges,80% of total billed charges,$36.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$89.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$104.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.62 ,$110.20 ,
XR Elbow Complete 3+ Views Left,1170127,CDM,320,RC,73080,HCPCS,outpatient,,,$398.26 ,$139.39 ,,$213.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.61 ,80,,,percent of total billed charges,80% of total billed charges,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$124.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$358.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$378.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.66 ,$378.35 ,
XR Elbow Complete 3+ Views Right,1170129,CDM,320,RC,73080,HCPCS,outpatient,,,$398.26 ,$139.39 ,,$213.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$298.70 ,75,,,percent of total billed charges,75% of total billed charges,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.61 ,80,,,percent of total billed charges,80% of total billed charges,$125.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$318.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$124.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$358.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$378.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$338.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.66 ,$378.35 ,
XR Facial Bones 3+ Views,1170141,CDM,320,RC,70150,HCPCS,outpatient,,,$522.00 ,$182.70 ,,$279.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$279.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$391.50 ,75,,,percent of total billed charges,75% of total billed charges,$391.50 ,75,,,percent of total billed charges,75% of total billed charges,$391.50 ,75,,,percent of total billed charges,75% of total billed charges,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$417.60 ,80,,,percent of total billed charges,80% of total billed charges,$165.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$182.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$417.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$365.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$365.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$401.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$161.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$469.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$104.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$495.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$417.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$485.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$391.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$391.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$391.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$443.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.79 ,$495.90 ,
XR Femur 2 Views Bilat,8211701,CDM,320,RC,73552,HCPCS,outpatient,,,$483.00 ,$169.05 ,,$258.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$258.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.40 ,80,,,percent of total billed charges,80% of total billed charges,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$169.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$386.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$338.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$371.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$149.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$434.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$458.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$386.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$449.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.19 ,$458.85 ,
XR Femur 2 Views Left,7520570,CDM,320,RC,73552,HCPCS,outpatient,,,$483.00 ,$169.05 ,,$258.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$258.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$362.25 ,75,,,percent of total billed charges,75% of total billed charges,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$386.40 ,80,,,percent of total billed charges,80% of total billed charges,$152.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$169.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$386.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$338.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$338.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$371.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$149.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$434.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$458.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$386.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$449.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$362.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$410.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.19 ,$458.85 ,
XR Femur 2 Views Right,7520573,CDM,320,RC,73552,HCPCS,outpatient,,,$290.00 ,$101.50 ,,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$223.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$261.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$275.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.55 ,$275.50 ,
XR Finger(2nd Digit) 2+ Views Left,28368,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
XR Finger(3rd Digit) 2+ Views Left,731402,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
XR Finger(4th Digit) 2+ Views Left,731401,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
XR Finger(4th Digit) 2+ Views Left,731401,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
XR Finger(4th Digit) 2+ Views Left,731401,CDM,320,RC,73140,HCPCS,outpatient,,,$216.00 ,$75.60 ,,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$162.00 ,75,,,percent of total billed charges,75% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges,$68.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.12 ,$205.20 ,
XR Finger(s) 2+ Views Left,1170151,CDM,320,RC,73140,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
XR Finger(s) 2+ Views Right,1170153,CDM,320,RC,73140,HCPCS,outpatient,,,$225.00 ,$78.75 ,,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$168.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges,$71.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,$213.75 ,
XR Fluoroscopy Over 1 Hour EO,8111110,CDM,320,RC,76001,HCPCS,outpatient,,,$435.00 ,$152.25 ,,$233.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.00 ,80,,,percent of total billed charges,80% of total billed charges,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$391.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$413.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$326.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$326.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$326.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.83 ,$413.25 ,
XR Fluoroscopy Under 1 Hour EO,28551,CDM,320,RC,76000,HCPCS,outpatient,,,$355.00 ,$124.25 ,,$190.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$190.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$266.25 ,75,,,percent of total billed charges,75% of total billed charges,$266.25 ,75,,,percent of total billed charges,75% of total billed charges,$266.25 ,75,,,percent of total billed charges,75% of total billed charges,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.00 ,80,,,percent of total billed charges,80% of total billed charges,$112.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$124.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$284.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$248.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$273.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$110.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$319.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$71.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$337.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$266.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$266.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$266.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.23 ,$337.25 ,
XR Foot 2 Views Left,73620,CDM,320,RC,73620,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
XR Foot 2 Views Left,1170185,CDM,320,RC,73620,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
XR Foot 2 Views Left Wt Bearing,8523061,CDM,320,RC,73620,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
XR Foot 2 Views Right,1170187,CDM,320,RC,73620,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
XR Foot 2 Views Right Wt Bearing,8523064,CDM,320,RC,73630,HCPCS,outpatient,,,$159.00 ,$55.65 ,,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$119.25 ,75,,,percent of total billed charges,75% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges,$50.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.01 ,$151.05 ,
XR Foot Complete 3+ Views Left,1170191,CDM,320,RC,73630,HCPCS,outpatient,,,$394.81 ,$138.18 ,,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$138.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$123.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$122.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$355.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$375.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$367.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.99 ,$375.07 ,
XR Foot Complete 3+ Views Right,1170193,CDM,320,RC,73630,HCPCS,outpatient,,,$394.81 ,$138.18 ,,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$211.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$296.11 ,75,,,percent of total billed charges,75% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges,$124.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$138.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$276.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$123.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$122.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$355.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$375.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$367.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.99 ,$375.07 ,
XR Forearm 2 Views Bilateral,1170195,CDM,320,RC,73090,HCPCS,outpatient,,,$218.00 ,$76.30 ,,$116.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$163.50 ,75,,,percent of total billed charges,75% of total billed charges,$163.50 ,75,,,percent of total billed charges,75% of total billed charges,$163.50 ,75,,,percent of total billed charges,75% of total billed charges,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$174.40 ,80,,,percent of total billed charges,80% of total billed charges,$68.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$76.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$174.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$152.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$196.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$207.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$163.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$163.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$163.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$185.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.51 ,$207.10 ,
XR Forearm 2 Views Left,1170197,CDM,320,RC,73090,HCPCS,outpatient,,,$720.77 ,$252.27 ,,$386.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$386.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$576.62 ,80,,,percent of total billed charges,80% of total billed charges,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$252.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$576.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$504.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$554.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$223.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$648.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$144.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$684.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$576.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$670.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.55 ,$684.73 ,
XR Forearm 2 Views Right,1170199,CDM,320,RC,73090,HCPCS,outpatient,,,$720.77 ,$252.27 ,,$386.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$386.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$540.58 ,75,,,percent of total billed charges,75% of total billed charges,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$576.62 ,80,,,percent of total billed charges,80% of total billed charges,$227.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$252.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$576.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$504.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$504.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$554.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$225.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$223.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$648.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$144.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$684.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$576.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$670.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$540.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$612.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.55 ,$684.73 ,
XR Foreign Body Localization Eye,1170203,CDM,320,RC,70030,HCPCS,outpatient,,,$127.00 ,$44.45 ,,$68.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$114.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$120.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.77 ,$120.65 ,
XR Foreign Body Localization Child 1 Vw,1170207,CDM,320,RC,76010,HCPCS,outpatient,,,$399.90 ,$139.97 ,,$214.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$214.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$299.93 ,75,,,percent of total billed charges,75% of total billed charges,$299.93 ,75,,,percent of total billed charges,75% of total billed charges,$299.93 ,75,,,percent of total billed charges,75% of total billed charges,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.92 ,80,,,percent of total billed charges,80% of total billed charges,$126.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$279.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$307.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$359.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$379.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$371.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$299.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$339.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.98 ,$379.91 ,
XR Hand 2 Views Left,1170215,CDM,320,RC,73120,HCPCS,outpatient,,,$609.77 ,$213.42 ,,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$213.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$469.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$189.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$548.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$579.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$567.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.91 ,$579.28 ,
XR Hand 2 Views Right,1170217,CDM,320,RC,73120,HCPCS,outpatient,,,$609.77 ,$213.42 ,,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$213.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$469.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$189.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$548.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$579.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$567.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.91 ,$579.28 ,
XR Hand Complete 3+ Views Right,73130,CDM,320,RC,73130,HCPCS,outpatient,,,$264.14 ,$92.45 ,,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$237.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.51 ,$250.93 ,
XR Hand Complete 3+ Views Bilateral,1170219,CDM,320,RC,73130,HCPCS,outpatient,,,$264.14 ,$92.45 ,,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$237.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.51 ,$250.93 ,
XR Hand Complete 3+ Views Left,1170221,CDM,320,RC,73130,HCPCS,outpatient,,,$264.14 ,$92.45 ,,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$237.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.51 ,$250.93 ,
XR Hand Complete 3+ Views Right,1170223,CDM,320,RC,73130,HCPCS,outpatient,,,$264.14 ,$92.45 ,,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$198.11 ,75,,,percent of total billed charges,75% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges,$83.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$237.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$198.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.51 ,$250.93 ,
XR Hand Complete 3+ Views Right,73130,CDM,320,RC,73130,HCPCS,outpatient,,,$281.00 ,$98.35 ,,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$210.75 ,75,,,percent of total billed charges,75% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges,$88.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$98.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$196.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$216.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$87.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$252.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$266.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$261.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$238.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.80 ,$266.95 ,
XR Hip 1 View Left,1170225,CDM,320,RC,73500,HCPCS,outpatient,,,$196.90 ,$68.92 ,,$105.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.52 ,80,,,percent of total billed charges,80% of total billed charges,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$68.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$177.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.40 ,$187.06 ,
XR Hip 1 View Right,1170227,CDM,320,RC,73501,HCPCS,outpatient,,,$196.90 ,$68.92 ,,$105.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$147.68 ,75,,,percent of total billed charges,75% of total billed charges,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.52 ,80,,,percent of total billed charges,80% of total billed charges,$62.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$68.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$177.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$167.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.40 ,$187.06 ,
XR Hip 2-3 Views Left,7520582,CDM,320,RC,73502,HCPCS,outpatient,,,$350.35 ,$122.62 ,,$187.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.76 ,75,,,percent of total billed charges,75% of total billed charges,$262.76 ,75,,,percent of total billed charges,75% of total billed charges,$262.76 ,75,,,percent of total billed charges,75% of total billed charges,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.28 ,80,,,percent of total billed charges,80% of total billed charges,$110.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$332.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$297.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.32 ,$332.83 ,
XR Hip 2-3 Views Right,7520585,CDM,320,RC,73502,HCPCS,outpatient,,,$490.00 ,$171.50 ,,$262.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$367.50 ,75,,,percent of total billed charges,75% of total billed charges,$367.50 ,75,,,percent of total billed charges,75% of total billed charges,$367.50 ,75,,,percent of total billed charges,75% of total billed charges,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$392.00 ,80,,,percent of total billed charges,80% of total billed charges,$154.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$171.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$392.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$343.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$343.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$377.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$151.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$441.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$98.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$465.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$392.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$97.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$455.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$367.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$367.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$367.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$98.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.55 ,$465.50 ,
XR Hips 3-4 Views Bilat,7520612,CDM,320,RC,73522,HCPCS,outpatient,,,$331.58 ,$116.05 ,,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$102.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$298.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$308.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.66 ,$315.00 ,
XR Humerus Bilat,8211785,CDM,320,RC,73060,HCPCS,outpatient,,,$326.00 ,$114.10 ,,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$244.50 ,75,,,percent of total billed charges,75% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges,$103.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$251.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$244.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.57 ,$309.70 ,
XR Humerus Left,1170245,CDM,320,RC,73060,HCPCS,outpatient,,,$331.58 ,$116.05 ,,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$102.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$298.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$308.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.66 ,$315.00 ,
XR Humerus Right,1170247,CDM,320,RC,73060,HCPCS,outpatient,,,$331.58 ,$116.05 ,,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$248.69 ,75,,,percent of total billed charges,75% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges,$104.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$102.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$298.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$308.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$248.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$281.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.66 ,$315.00 ,
XR Knee 1 or 2 Views Right,753601,CDM,320,RC,75360,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
XR Knee 1 or 2 Views Left,75360,CDM,320,RC,75360,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
XR Knee 1 or 2 Views Bilateral,1170261,CDM,320,RC,73560,HCPCS,outpatient,,,$449.00 ,$157.15 ,,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$345.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$426.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$417.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.56 ,$426.55 ,
XR Knee 1 or 2 Views Left,1170263,CDM,320,RC,73560,HCPCS,outpatient,,,$449.00 ,$157.15 ,,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$345.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$426.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$417.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.56 ,$426.55 ,
XR Knee 1 or 2 Views Right,1170265,CDM,320,RC,73560,HCPCS,outpatient,,,$449.00 ,$157.15 ,,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$240.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$336.75 ,75,,,percent of total billed charges,75% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges,$141.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$157.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$314.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$345.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$139.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$404.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$426.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$417.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$336.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$381.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.56 ,$426.55 ,
XR Knee 3 Views Bilateral,1170267,CDM,320,RC,73562,HCPCS,outpatient,,,$421.36 ,$147.48 ,,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$147.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$324.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$130.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$379.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$400.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.17 ,$400.29 ,
XR Knee 3 Views Left,1170269,CDM,320,RC,73562,HCPCS,outpatient,,,$421.36 ,$147.48 ,,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$147.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$324.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$130.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$379.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$400.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.17 ,$400.29 ,
XR Knee 3 Views Right,28074,CDM,320,RC,73562,HCPCS,outpatient,,,$424.88 ,$148.71 ,,$227.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$318.66 ,75,,,percent of total billed charges,75% of total billed charges,$318.66 ,75,,,percent of total billed charges,75% of total billed charges,$318.66 ,75,,,percent of total billed charges,75% of total billed charges,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$339.90 ,80,,,percent of total billed charges,80% of total billed charges,$134.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$148.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$297.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$327.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$131.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$382.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$403.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$395.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$318.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.85 ,$403.64 ,
XR Knee 3 Views Right,1170271,CDM,320,RC,73562,HCPCS,outpatient,,,$421.36 ,$147.48 ,,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$316.02 ,75,,,percent of total billed charges,75% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges,$133.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$147.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$324.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$130.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$379.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$400.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$337.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$391.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$316.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$358.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.17 ,$400.29 ,
XR Knee Complete 4+ Views Left,1170287,CDM,320,RC,73564,HCPCS,outpatient,,,$578.00 ,$202.30 ,,$309.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$462.40 ,80,,,percent of total billed charges,80% of total billed charges,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$202.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$462.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$404.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$445.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$179.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$520.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$116.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$549.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.71 ,$549.10 ,
XR Knee Complete 4+ Views Right,1170289,CDM,320,RC,73564,HCPCS,outpatient,,,$578.00 ,$202.30 ,,$309.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$433.50 ,75,,,percent of total billed charges,75% of total billed charges,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$462.40 ,80,,,percent of total billed charges,80% of total billed charges,$182.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$202.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$462.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$404.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$445.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$179.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$520.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$116.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$549.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$433.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$491.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.71 ,$549.10 ,
XR Lower Extremity Infant (0-1yr) Left,1170297,CDM,320,RC,73592,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
XR Lower Extremity Infant (0-1yr) Right,1170299,CDM,320,RC,73592,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
XR Mandible Less Than 4 Views,1170303,CDM,320,RC,70110,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
XR Mastoids Complete,1170315,CDM,320,RC,70130,HCPCS,outpatient,,,$196.00 ,$68.60 ,,$105.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$147.00 ,75,,,percent of total billed charges,75% of total billed charges,$147.00 ,75,,,percent of total billed charges,75% of total billed charges,$147.00 ,75,,,percent of total billed charges,75% of total billed charges,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$156.80 ,80,,,percent of total billed charges,80% of total billed charges,$61.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$68.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$150.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$60.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$176.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$186.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$147.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$147.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.22 ,$186.20 ,
XR Nasal Bones 3+ Views,1170329,CDM,320,RC,70160,HCPCS,outpatient,,,$147.00 ,$51.45 ,,$78.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.25 ,75,,,percent of total billed charges,75% of total billed charges,$110.25 ,75,,,percent of total billed charges,75% of total billed charges,$110.25 ,75,,,percent of total billed charges,75% of total billed charges,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.60 ,80,,,percent of total billed charges,80% of total billed charges,$46.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$51.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$45.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$132.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$139.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$110.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$124.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.67 ,$139.65 ,
XR Neck Soft Tissue,1170331,CDM,320,RC,70360,HCPCS,outpatient,,,$288.00 ,$100.80 ,,$154.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.00 ,75,,,percent of total billed charges,75% of total billed charges,$216.00 ,75,,,percent of total billed charges,75% of total billed charges,$216.00 ,75,,,percent of total billed charges,75% of total billed charges,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$230.40 ,80,,,percent of total billed charges,80% of total billed charges,$91.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$100.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$230.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$201.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$221.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$259.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$57.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$273.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$244.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.16 ,$273.60 ,
XR Orbits Complete,1170339,CDM,320,RC,70200,HCPCS,outpatient,,,$217.00 ,$75.95 ,,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$162.75 ,75,,,percent of total billed charges,75% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges,$68.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$167.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$195.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$206.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$184.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.32 ,$206.15 ,
XR Pelvis 1 or 2 Views,1170351,CDM,320,RC,72170,HCPCS,outpatient,,,$299.00 ,$104.65 ,,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$224.25 ,75,,,percent of total billed charges,75% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges,$94.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$104.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$92.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$269.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$284.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$224.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$224.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$254.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.31 ,$284.05 ,
XR Pelvis Complete 3+ Views,1170353,CDM,320,RC,72190,HCPCS,outpatient,,,$324.90 ,$113.72 ,,$174.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$243.68 ,75,,,percent of total billed charges,75% of total billed charges,$243.68 ,75,,,percent of total billed charges,75% of total billed charges,$243.68 ,75,,,percent of total billed charges,75% of total billed charges,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$259.92 ,80,,,percent of total billed charges,80% of total billed charges,$102.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$113.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$250.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$100.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$292.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$308.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$243.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$276.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.36 ,$308.66 ,
XR Ribs 3 Views Bilateral,28060,CDM,320,RC,71110,HCPCS,outpatient,,,$416.64 ,$145.82 ,,$223.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$223.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$312.48 ,75,,,percent of total billed charges,75% of total billed charges,$312.48 ,75,,,percent of total billed charges,75% of total billed charges,$312.48 ,75,,,percent of total billed charges,75% of total billed charges,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.31 ,80,,,percent of total billed charges,80% of total billed charges,$131.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$145.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$333.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$291.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$320.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$129.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$374.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$395.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$333.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$387.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$312.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$354.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.24 ,$395.81 ,
XR Ribs 3 Views Left,8102145,CDM,320,RC,71101,HCPCS,outpatient,,,$436.00 ,$152.60 ,,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$335.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$392.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$414.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$405.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.02 ,$414.20 ,
XR Ribs 3 Views Right,8102148,CDM,320,RC,71101,HCPCS,outpatient,,,$436.00 ,$152.60 ,,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$335.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$392.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$414.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$405.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.02 ,$414.20 ,
XR Ribs w/ PA Chest Bilateral,1170377,CDM,324,RC,71111,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
XR Ribs w/ PA Chest Left,1170379,CDM,320,RC,71101,HCPCS,outpatient,,,$436.00 ,$152.60 ,,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$335.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$392.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$414.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$405.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.02 ,$414.20 ,
XR Ribs w/ PA Chest Right,1170381,CDM,320,RC,71101,HCPCS,outpatient,,,$436.00 ,$152.60 ,,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$327.00 ,75,,,percent of total billed charges,75% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges,$137.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$305.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$335.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$392.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$414.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$405.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$327.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$370.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.02 ,$414.20 ,
XR Sacroiliac Joints 1 or 2 Views,1170385,CDM,320,RC,72202,HCPCS,outpatient,,,$434.00 ,$151.90 ,,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$151.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$390.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$412.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.63 ,$412.30 ,
XR Sacrum/Coccyx 2+ Views,1170391,CDM,320,RC,72220,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
XR Scapula Left,1170401,CDM,320,RC,73010,HCPCS,outpatient,,,$186.00 ,$65.10 ,,$99.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.50 ,75,,,percent of total billed charges,75% of total billed charges,$139.50 ,75,,,percent of total billed charges,75% of total billed charges,$139.50 ,75,,,percent of total billed charges,75% of total billed charges,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.80 ,80,,,percent of total billed charges,80% of total billed charges,$58.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$143.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$167.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$176.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.27 ,$176.70 ,
XR Scapula Right,1170403,CDM,320,RC,73010,HCPCS,outpatient,,,$175.00 ,$61.25 ,,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$131.25 ,75,,,percent of total billed charges,75% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges,$55.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.13 ,$166.25 ,
XR Shoulder 1 View Left,1170409,CDM,320,RC,73020,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
XR Shoulder 1 View Right,1170411,CDM,320,RC,73020,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
XR Shoulder Complete 2+ Views Left,1170415,CDM,320,RC,73030,HCPCS,outpatient,,,$317.53 ,$111.14 ,,$170.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$254.02 ,80,,,percent of total billed charges,80% of total billed charges,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$111.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.92 ,$301.65 ,
XR Shoulder Complete 2+ Views Right,1170417,CDM,320,RC,73030,HCPCS,outpatient,,,$317.53 ,$111.14 ,,$170.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$238.15 ,75,,,percent of total billed charges,75% of total billed charges,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$254.02 ,80,,,percent of total billed charges,80% of total billed charges,$100.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$111.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$238.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.92 ,$301.65 ,
XR Shunt Series,2425608,CDM,320,RC,75809,HCPCS,outpatient,,,$588.00 ,$205.80 ,,$315.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$315.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$441.00 ,75,,,percent of total billed charges,75% of total billed charges,$441.00 ,75,,,percent of total billed charges,75% of total billed charges,$441.00 ,75,,,percent of total billed charges,75% of total billed charges,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.40 ,80,,,percent of total billed charges,80% of total billed charges,$185.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$205.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$470.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$411.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$411.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$452.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$182.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$529.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$118.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$558.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$470.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$116.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$546.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$441.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$441.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$441.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$118.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$499.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.66 ,$558.60 ,
XR Sinuses Paranasal < 3 Views,1170432,CDM,320,RC,70210,HCPCS,outpatient,,,$207.00 ,$72.45 ,,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$155.25 ,75,,,percent of total billed charges,75% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges,$65.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$186.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.37 ,$196.65 ,
XR Sinuses Paranasal Complete,1170434,CDM,320,RC,70220,HCPCS,outpatient,,,$174.00 ,$60.90 ,,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$60.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$53.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$156.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.93 ,$165.30 ,
XR Skull < 4 Views,1170436,CDM,320,RC,70250,HCPCS,outpatient,,,$540.00 ,$189.00 ,,$289.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$289.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$405.00 ,75,,,percent of total billed charges,75% of total billed charges,$405.00 ,75,,,percent of total billed charges,75% of total billed charges,$405.00 ,75,,,percent of total billed charges,75% of total billed charges,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$432.00 ,80,,,percent of total billed charges,80% of total billed charges,$170.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$189.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$432.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$378.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$415.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$167.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$486.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$108.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$513.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$432.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$405.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$405.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$405.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$459.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.30 ,$513.00 ,
XR Skull Complete,1170438,CDM,320,RC,70260,HCPCS,outpatient,,,$272.00 ,$95.20 ,,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$145.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$204.00 ,75,,,percent of total billed charges,75% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges,$86.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$209.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$244.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$258.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$204.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.04 ,$258.40 ,
XR Spine Cervical 4 or 5 Views,72050,CDM,320,RC,72050,HCPCS,outpatient,,,"$1,070.61 ",$374.71 ,,$573.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$573.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$856.49 ,80,,,percent of total billed charges,80% of total billed charges,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$374.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$856.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$749.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$749.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$824.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$331.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$963.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,017.08 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$856.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$995.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.77 ,"$1,017.08 ",
XR Spine Cervical 1 View,1170446,CDM,320,RC,72020,HCPCS,outpatient,,,$317.00 ,$110.95 ,,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.82 ,$301.15 ,
XR Spine Cervical 2 or 3 Views,72040,CDM,320,RC,72040,HCPCS,outpatient,,,$663.00 ,$232.05 ,,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$497.25 ,75,,,percent of total billed charges,75% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges,$209.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$232.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$464.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$510.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$205.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$596.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$629.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$530.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$616.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$497.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$563.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.29 ,$629.85 ,
XR Spine Cervical 4 or 5 Views,1170454,CDM,320,RC,72050,HCPCS,outpatient,,,"$1,070.61 ",$374.71 ,,$573.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$573.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$802.96 ,75,,,percent of total billed charges,75% of total billed charges,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$856.49 ,80,,,percent of total billed charges,80% of total billed charges,$338.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$374.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$856.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$749.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$749.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$824.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$331.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$963.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,017.08 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$856.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$995.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$802.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$910.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.77 ,"$1,017.08 ",
XR Spine Cervical Flexion + Extension,8367331,CDM,320,RC,72052,HCPCS,outpatient,,,$434.00 ,$151.90 ,,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$232.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$325.50 ,75,,,percent of total billed charges,75% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges,$137.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$151.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$303.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$390.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$412.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$347.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$403.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$325.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$368.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.63 ,$412.30 ,
XR Spine Lumbar 1 View,28061,CDM,320,RC,72020,HCPCS,outpatient,,,$317.00 ,$110.95 ,,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.82 ,$301.15 ,
XR Spine Lumbar 4+ Views,8426466,CDM,320,RC,72110,HCPCS,outpatient,,,$860.00 ,$301.00 ,,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$460.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$645.00 ,75,,,percent of total billed charges,75% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges,$271.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$301.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$602.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$662.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$266.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$774.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$817.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$688.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$799.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$645.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$731.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$167.70 ,$817.00 ,
XR Spine Lumbosacral 4+ Views,72110,CDM,320,RC,72110,HCPCS,outpatient,,,"$1,204.94 ",$421.73 ,,$645.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$645.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$963.95 ,80,,,percent of total billed charges,80% of total billed charges,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$421.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$843.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$927.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$373.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,084.45 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$241.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,144.69 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.59 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.96 ,"$1,144.69 ",
XR Spine Lumbosacral 2 or 3 Views,72100,CDM,320,RC,72100,HCPCS,outpatient,,,$992.84 ,$347.49 ,,$532.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$532.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$744.63 ,75,,,percent of total billed charges,75% of total billed charges,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$794.27 ,80,,,percent of total billed charges,80% of total billed charges,$313.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$347.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$794.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$694.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$694.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$764.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$310.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$307.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$893.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$199.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$943.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$923.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$744.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$199.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$843.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.60 ,$943.20 ,
XR Spine Lumbosacral w/ Bending 6+ Views,1170474,CDM,320,RC,72114,HCPCS,outpatient,,,$410.00 ,$143.50 ,,$219.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$219.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$307.50 ,75,,,percent of total billed charges,75% of total billed charges,$307.50 ,75,,,percent of total billed charges,75% of total billed charges,$307.50 ,75,,,percent of total billed charges,75% of total billed charges,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$328.00 ,80,,,percent of total billed charges,80% of total billed charges,$129.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$143.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$287.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$287.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$369.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$389.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$307.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$348.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.95 ,$389.50 ,
XR Spine Lumbosacral 4+ Views,28072,CDM,320,RC,72110,HCPCS,outpatient,,,"$1,204.94 ",$421.73 ,,$645.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$645.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$903.71 ,75,,,percent of total billed charges,75% of total billed charges,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$963.95 ,80,,,percent of total billed charges,80% of total billed charges,$381.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$421.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$843.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$843.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$927.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$377.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$373.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,084.45 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$241.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,144.69 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,120.59 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$903.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$241.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,024.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.96 ,"$1,144.69 ",
XR Spine Scoliosis 1 View,7520627,CDM,320,RC,72081,HCPCS,outpatient,,,$218.90 ,$76.62 ,,$117.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$164.18 ,75,,,percent of total billed charges,75% of total billed charges,$164.18 ,75,,,percent of total billed charges,75% of total billed charges,$164.18 ,75,,,percent of total billed charges,75% of total billed charges,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$175.12 ,80,,,percent of total billed charges,80% of total billed charges,$69.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$76.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$175.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$168.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$67.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$197.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$207.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$164.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$164.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$186.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.69 ,$207.96 ,
XR Spine Scoliosis 2-3 Views,7520630,CDM,320,RC,72082,HCPCS,outpatient,,,$526.00 ,$184.10 ,,$281.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$281.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$394.50 ,75,,,percent of total billed charges,75% of total billed charges,$394.50 ,75,,,percent of total billed charges,75% of total billed charges,$394.50 ,75,,,percent of total billed charges,75% of total billed charges,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$420.80 ,80,,,percent of total billed charges,80% of total billed charges,$166.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$184.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$420.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$368.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$405.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$164.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$163.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$473.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$105.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$499.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$420.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$104.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$489.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$394.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$394.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$394.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$447.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.57 ,$499.70 ,
XR Spine Thoracic 1 View,1170450,CDM,320,RC,72020,HCPCS,outpatient,,,$104.00 ,$36.40 ,,$55.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$78.00 ,75,,,percent of total billed charges,75% of total billed charges,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.20 ,80,,,percent of total billed charges,80% of total billed charges,$32.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$93.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.28 ,$98.80 ,
XR Spine Thoracic 2 Views,1170484,CDM,320,RC,72070,HCPCS,outpatient,,,$609.77 ,$213.42 ,,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$326.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$457.33 ,75,,,percent of total billed charges,75% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges,$192.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$213.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$426.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$469.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$189.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$548.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$579.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$567.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$457.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$518.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.91 ,$579.28 ,
XR Spine Thoracic 3 Views,72072,CDM,320,RC,72072,HCPCS,outpatient,,,$652.00 ,$228.20 ,,$349.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$349.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$489.00 ,75,,,percent of total billed charges,75% of total billed charges,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$521.60 ,80,,,percent of total billed charges,80% of total billed charges,$206.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$228.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$521.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$456.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$456.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$502.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$202.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$586.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$130.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$619.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$521.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$606.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$554.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.14 ,$619.40 ,
XR Sternum 2+ Views,1170496,CDM,320,RC,71120,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
XR TMJ Open and Closed Bilateral,1170502,CDM,320,RC,70330,HCPCS,outpatient,,,$305.00 ,$106.75 ,,$163.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$163.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$228.75 ,75,,,percent of total billed charges,75% of total billed charges,$228.75 ,75,,,percent of total billed charges,75% of total billed charges,$228.75 ,75,,,percent of total billed charges,75% of total billed charges,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.00 ,80,,,percent of total billed charges,80% of total billed charges,$96.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$106.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$244.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$213.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$234.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$94.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$274.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$61.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$289.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$228.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$228.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$228.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$259.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.48 ,$289.75 ,
XR TMJ Open and Closed Left,8100061,CDM,320,RC,70328,HCPCS,outpatient,,,$199.90 ,$69.97 ,,$107.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.92 ,80,,,percent of total billed charges,80% of total billed charges,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.98 ,$189.91 ,
XR TMJ Open and Closed Right,8100063,CDM,320,RC,70328,HCPCS,outpatient,,,$199.90 ,$69.97 ,,$107.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$149.93 ,75,,,percent of total billed charges,75% of total billed charges,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.92 ,80,,,percent of total billed charges,80% of total billed charges,$63.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.98 ,$189.91 ,
XR Tibia/Fibula Left,1170516,CDM,320,RC,73590,HCPCS,outpatient,,,$317.00 ,$110.95 ,,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$237.75 ,75,,,percent of total billed charges,75% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges,$100.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$110.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$221.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$98.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$285.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$301.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$237.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.82 ,$301.15 ,
XR Tibia/Fibula Right,1170518,CDM,320,RC,73590,HCPCS,outpatient,,,$226.66 ,$79.33 ,,$121.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.00 ,75,,,percent of total billed charges,75% of total billed charges,$170.00 ,75,,,percent of total billed charges,75% of total billed charges,$170.00 ,75,,,percent of total billed charges,75% of total billed charges,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$181.33 ,80,,,percent of total billed charges,80% of total billed charges,$71.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$158.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$174.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$203.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$170.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$192.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.20 ,$215.33 ,
XR Toe(s) 2+ Views Right,18059,CDM,320,RC,73660,HCPCS,outpatient,,,$211.20 ,$73.92 ,,$113.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.40 ,75,,,percent of total billed charges,75% of total billed charges,$158.40 ,75,,,percent of total billed charges,75% of total billed charges,$158.40 ,75,,,percent of total billed charges,75% of total billed charges,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.96 ,80,,,percent of total billed charges,80% of total billed charges,$66.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$73.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$147.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$190.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$158.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.18 ,$200.64 ,
XR Toe(s) 2+ Views Left,28385,CDM,320,RC,73660,HCPCS,outpatient,,,$220.00 ,$77.00 ,,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$77.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$169.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$68.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$198.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.90 ,$209.00 ,
XR Toe(s) 2+ Views Left,1170520,CDM,320,RC,73660,HCPCS,outpatient,,,$220.00 ,$77.00 ,,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$77.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$169.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$68.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$198.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.90 ,$209.00 ,
XR Toe(s) 2+ Views Right,1170522,CDM,320,RC,73660,HCPCS,outpatient,,,$220.00 ,$77.00 ,,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$165.00 ,75,,,percent of total billed charges,75% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges,$69.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$77.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$169.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$68.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$198.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.90 ,$209.00 ,
XR Tube Placement NG Gastric (Stomach),2425629,CDM,320,RC,43752,HCPCS,outpatient,,,$598.00 ,$209.30 ,,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$320.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$448.50 ,75,,,percent of total billed charges,75% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges,$189.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$209.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$418.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$460.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$185.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$538.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$568.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$448.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$508.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$116.61 ,$568.10 ,
XR Upper Extremity Infant (0-1yr) Left,1170558,CDM,320,RC,73092,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
XR Upper Extremity Infant (0-1yr) Right,28542,CDM,320,RC,73092,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$135.75 ,75,,,percent of total billed charges,75% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges,$57.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.30 ,$171.95 ,
XR Urethrocystography Retrograde,1170578,CDM,320,RC,74420,HCPCS,outpatient,,,$409.90 ,$143.47 ,,$219.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$219.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$307.43 ,75,,,percent of total billed charges,75% of total billed charges,$307.43 ,75,,,percent of total billed charges,75% of total billed charges,$307.43 ,75,,,percent of total billed charges,75% of total billed charges,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.92 ,80,,,percent of total billed charges,80% of total billed charges,$129.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$143.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$327.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$286.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$286.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$368.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$389.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$307.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$348.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.93 ,$389.41 ,
XR Wrist 2 Views Left,1170606,CDM,320,RC,73100,HCPCS,outpatient,,,$389.00 ,$136.15 ,,$208.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$208.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$311.20 ,80,,,percent of total billed charges,80% of total billed charges,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$136.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$272.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$299.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$120.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$350.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$78.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$369.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.86 ,$369.55 ,
XR Wrist 2 Views Right,1170608,CDM,320,RC,73100,HCPCS,outpatient,,,$389.00 ,$136.15 ,,$208.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$208.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$291.75 ,75,,,percent of total billed charges,75% of total billed charges,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$311.20 ,80,,,percent of total billed charges,80% of total billed charges,$123.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$136.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$272.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$299.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$120.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$350.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$78.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$369.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$291.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$330.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.86 ,$369.55 ,
XR Wrist Complete 3+ Views Left,1170612,CDM,320,RC,73110,HCPCS,outpatient,,,$369.66 ,$129.38 ,,$198.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$295.73 ,80,,,percent of total billed charges,80% of total billed charges,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$129.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$284.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$114.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$332.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$74.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$351.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$343.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.08 ,$351.18 ,
XR Wrist Complete 3+ Views Right,1170614,CDM,320,RC,73110,HCPCS,outpatient,,,$369.66 ,$129.38 ,,$198.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$198.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$277.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$295.73 ,80,,,percent of total billed charges,80% of total billed charges,$116.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$129.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$258.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$284.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$114.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$332.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$74.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$351.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$343.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$277.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$314.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.08 ,$351.18 ,
XR Zygomatic Arches,18013,CDM,320,RC,70150,HCPCS,outpatient,,,$501.12 ,$175.39 ,,$268.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.84 ,75,,,percent of total billed charges,75% of total billed charges,$375.84 ,75,,,percent of total billed charges,75% of total billed charges,$375.84 ,75,,,percent of total billed charges,75% of total billed charges,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.90 ,80,,,percent of total billed charges,80% of total billed charges,$158.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$451.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$476.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.67 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.72 ,$476.06 ,
31500 INTUBATION CHARGE,31500,CDM,410,RC,31500,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
94010 Basic Spirometry Charge,12019,CDM,410,RC,94010,HCPCS,outpatient,,,$246.72 ,$86.35 ,,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$222.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$234.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.11 ,$234.38 ,
94010 PFT Simple Spirometry CHARGE,,CDM,410,RC,94010,HCPCS,outpatient,,,$257.00 ,$89.95 ,,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$197.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$231.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$244.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.12 ,$244.15 ,
94640 AEROSOL TREATMENT INITIAL CHARGE,94640,CDM,410,RC,94640,HCPCS,outpatient,,,$768.00 ,$268.80 ,,$411.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$576.00 ,75,,,percent of total billed charges,75% of total billed charges,$576.00 ,75,,,percent of total billed charges,75% of total billed charges,$576.00 ,75,,,percent of total billed charges,75% of total billed charges,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$614.40 ,80,,,percent of total billed charges,80% of total billed charges,$242.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$614.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$537.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$591.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$238.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$691.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$154.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$729.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$614.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$714.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$576.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$576.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$576.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$154.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$652.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.76 ,$729.60 ,
94669 MECH CHEST WALL OSCILLATION LUNG FUNCT CHARGE,20372,CDM,410,RC,94669,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
97530 THERAPEUTIC ACTIVITIES CHARGE,8242788,CDM,420,RC,97530,HCPCS,outpatient,,,$89.00 ,$31.15 ,,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$66.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges,$28.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.36 ,$84.55 ,
RT Aerosol Initial CHARGE,12002,CDM,410,RC,94640,HCPCS,outpatient,,,$549.12 ,$192.19 ,,$294.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$294.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$411.84 ,75,,,percent of total billed charges,75% of total billed charges,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$439.30 ,80,,,percent of total billed charges,80% of total billed charges,$173.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$192.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$384.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$422.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$170.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$494.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$110.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$521.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$510.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$411.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$466.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.08 ,$521.66 ,
RT Aerosol Subsequent CHARGE,12032,CDM,410,RC,94640,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
RT Airway Suction CHARGE,20358,CDM,410,RC,31720,HCPCS,outpatient,,,$200.00 ,$70.00 ,,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$180.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.00 ,$190.00 ,
RT Arterial Puncture CHARGE,12007,CDM,300,RC,36600,HCPCS,outpatient,,,$111.95 ,$39.18 ,,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$55.98 ,75,,,percent of total billed charges,75% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.83 ,$106.35 ,
RT BiPAP Initial CHARGE,7050,CDM,410,RC,94660,HCPCS,outpatient,,,$343.20 ,$120.12 ,,$183.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$183.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.40 ,75,,,percent of total billed charges,75% of total billed charges,$257.40 ,75,,,percent of total billed charges,75% of total billed charges,$257.40 ,75,,,percent of total billed charges,75% of total billed charges,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$274.56 ,80,,,percent of total billed charges,80% of total billed charges,$108.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$120.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$274.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$240.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$264.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$107.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$106.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$308.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$68.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$326.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$257.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$257.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$257.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$291.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.92 ,$326.04 ,
RT CPAP Initial CHARGE,7049,CDM,410,RC,94660,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
RT CPT Initial CHARGE,12011,CDM,410,RC,94667,HCPCS,outpatient,,,$250.00 ,$87.50 ,,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$187.50 ,75,,,percent of total billed charges,75% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges,$79.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$87.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$77.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$225.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$237.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$187.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.75 ,$237.50 ,
RT CPT Subsequent CHARGE,7060,CDM,410,RC,94668,HCPCS,outpatient,,,$200.00 ,$70.00 ,,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$150.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges,$63.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$180.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.00 ,$190.00 ,
RT Cardiopulmonary Resuscitation CHARGE,12013,CDM,410,RC,92950,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
RT Continuous Neb Initial CHARGE,7059,CDM,410,RC,94644,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
RT Continuous Neb Initial Charge,7059,CDM,410,RC,94644,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
RT Continuous Neb Subsequent Charge,7058,CDM,410,RC,94645,HCPCS,outpatient,,,$37.00 ,$12.95 ,,$19.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.75 ,75,,,percent of total billed charges,75% of total billed charges,$27.75 ,75,,,percent of total billed charges,75% of total billed charges,$27.75 ,75,,,percent of total billed charges,75% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.60 ,80,,,percent of total billed charges,80% of total billed charges,$11.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.22 ,$35.15 ,
RT Flutter Therapy Initial CHARGE,170611,CDM,270,RC,,HCPCS,outpatient,,,$257.00 ,$89.95 ,,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$137.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$192.75 ,75,,,percent of total billed charges,75% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges,$81.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$197.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$231.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$244.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.12 ,$244.15 ,
RT IPPB Initial CHARGE,12021,CDM,410,RC,94664,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
RT IPPB Subsequent CHARGE,12999,CDM,410,RC,94640,HCPCS,outpatient,,,$284.00 ,$99.40 ,,$152.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.00 ,75,,,percent of total billed charges,75% of total billed charges,$213.00 ,75,,,percent of total billed charges,75% of total billed charges,$213.00 ,75,,,percent of total billed charges,75% of total billed charges,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$227.20 ,80,,,percent of total billed charges,80% of total billed charges,$89.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$99.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$198.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$218.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$88.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$255.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$57.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$269.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$213.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$241.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.38 ,$269.80 ,
RT Oxygen Hours CHARGE,12026,CDM,271,RC,,HCPCS,outpatient,,,$22.00 ,$7.70 ,,$11.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,75,,,percent of total billed charges,75% of total billed charges,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.60 ,80,,,percent of total billed charges,80% of total billed charges,$6.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.29 ,$20.90 ,
RT Peak Flow Procedure CHARGE,11609,CDM,270,RC,,HCPCS,outpatient,,,$83.00 ,$29.05 ,,$44.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.25 ,75,,,percent of total billed charges,75% of total billed charges,$62.25 ,75,,,percent of total billed charges,75% of total billed charges,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,80,,,percent of total billed charges,80% of total billed charges,$26.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$74.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$62.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.19 ,$78.85 ,
RT Smoking Cessation Visit >10 min,30209,CDM,942,RC,99407,HCPCS,outpatient,,,$125.00 ,$43.75 ,,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$93.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges,$39.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$112.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,$118.75 ,
RT Smoking Cessation Visit 3-10 min,30208,CDM,942,RC,99406,HCPCS,outpatient,,,$93.00 ,$32.55 ,,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.14 ,$88.35 ,
RT Ventilator Services Initial CHARGE,7047,CDM,410,RC,94002,HCPCS,outpatient,,,"$1,789.44 ",$626.30 ,,$959.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$959.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,431.55 ",80,,,percent of total billed charges,80% of total billed charges,$565.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$626.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,431.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,252.61 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,252.61 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,377.87 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$560.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$560.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$554.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,610.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$359.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,699.97 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,431.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$355.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,664.18 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,342.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$359.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,521.02 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$348.94 ,"$1,699.97 ",
RT Ventilator Services Subsequent CHARGE,7048,CDM,410,RC,94003,HCPCS,outpatient,,,$766.08 ,$268.13 ,,$410.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$410.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$574.56 ,75,,,percent of total billed charges,75% of total billed charges,$574.56 ,75,,,percent of total billed charges,75% of total billed charges,$574.56 ,75,,,percent of total billed charges,75% of total billed charges,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$612.86 ,80,,,percent of total billed charges,80% of total billed charges,$242.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$268.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$239.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$612.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$536.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$536.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$589.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$239.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$239.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$239.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$237.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$689.47 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$153.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$727.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$612.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$712.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$574.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$574.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$574.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$651.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.39 ,$727.78 ,
Speech Sound Prod w/ Language Charge,8170124,CDM,440,RC,92523,HCPCS,outpatient,,,$362.00 ,$126.70 ,,$194.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$194.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$289.60 ,80,,,percent of total billed charges,80% of total billed charges,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$289.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$253.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$112.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$325.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$343.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.59 ,$343.90 ,
Treatment of Swallowing Dysfunction Charge,8171650,CDM,440,RC,92526,HCPCS,outpatient,,,$254.00 ,$88.90 ,,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$190.50 ,75,,,percent of total billed charges,75% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges,$80.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$195.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$228.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$241.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.53 ,$241.30 ,
Tx of Speech/Lang/Voice/Comm/Auditory Chg,8169572,CDM,440,RC,92507,HCPCS,outpatient,,,$290.00 ,$101.50 ,,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$217.50 ,75,,,percent of total billed charges,75% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges,$91.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$223.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$261.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$275.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.55 ,$275.50 ,
CT Chest Screening (LAKE),28915,CDM,352,RC,71271,HCPCS,outpatient,,,"$1,365.00 ",$477.75 ,,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$731.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges,$431.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$477.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$955.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,051.05 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$427.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$423.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,228.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,296.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,092.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,269.45 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,023.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,160.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$266.18 ,"$1,296.75 ",
92523 SPEECH EVALUATION Charge,10524597,CDM,440,RC,92523,HCPCS,outpatient,,,$362.00 ,$126.70 ,,$194.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$194.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$271.50 ,75,,,percent of total billed charges,75% of total billed charges,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$289.60 ,80,,,percent of total billed charges,80% of total billed charges,$114.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$289.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$253.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$253.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$278.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$112.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$325.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$343.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$307.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.59 ,$343.90 ,
97535 SELF CARE/ADLS Charge,10524593,CDM,420,RC,97535,HCPCS,outpatient,,,$75.00 ,$26.25 ,,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$56.25 ,75,,,percent of total billed charges,75% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges,$23.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$56.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,$71.25 ,
ABD PAD,11139,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ABDOMINAL TRANSDUCER STRAP,11783,CDM,270,RC,,HCPCS,outpatient,,,$10.88 ,$3.81 ,,$5.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.16 ,75,,,percent of total billed charges,75% of total billed charges,$8.16 ,75,,,percent of total billed charges,75% of total billed charges,$8.16 ,75,,,percent of total billed charges,75% of total billed charges,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.70 ,80,,,percent of total billed charges,80% of total billed charges,$3.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.81 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.12 ,$10.34 ,
ACAPELLA DH,17061,CDM,270,RC,,HCPCS,outpatient,,,$169.75 ,$59.41 ,,$90.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$127.31 ,75,,,percent of total billed charges,75% of total billed charges,$127.31 ,75,,,percent of total billed charges,75% of total billed charges,$127.31 ,75,,,percent of total billed charges,75% of total billed charges,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.80 ,80,,,percent of total billed charges,80% of total billed charges,$53.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$152.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$161.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$127.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$127.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$144.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.10 ,$161.26 ,
ACE BANDAGE 2 ELASTIC,11007,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ACE BANDAGE 3 ELASTIC,11008,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ACE BANDAGE 4 ELASTIC,11054,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ACE BANDAGE 6 ELASTIC,11055,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ADAPTIC DRESSING 3 X 8,11230,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ADHESIVE REMOVAL PAD,CDM,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
AIR TRANSFER MATRESS 50 (HOVERMAT),12606,CDM,270,RC,,HCPCS,outpatient,,,$252.88 ,$88.51 ,,$135.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.66 ,75,,,percent of total billed charges,75% of total billed charges,$189.66 ,75,,,percent of total billed charges,75% of total billed charges,$189.66 ,75,,,percent of total billed charges,75% of total billed charges,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$202.30 ,80,,,percent of total billed charges,80% of total billed charges,$79.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$88.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$202.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$177.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$194.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$79.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$78.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$227.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$50.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$240.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$189.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$189.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$214.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.31 ,$240.24 ,
AIR TRANSFER MATRESS 34 (HOVERMAT),12438,CDM,270,RC,,HCPCS,outpatient,,,$403.33 ,$141.17 ,,$216.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$302.50 ,75,,,percent of total billed charges,75% of total billed charges,$302.50 ,75,,,percent of total billed charges,75% of total billed charges,$302.50 ,75,,,percent of total billed charges,75% of total billed charges,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$322.66 ,80,,,percent of total billed charges,80% of total billed charges,$127.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$141.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$322.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$282.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$310.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$125.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$363.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$383.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$322.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$302.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$302.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$302.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.65 ,$383.16 ,
AIR WAY LARGE 10,12005,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIR WAY MED. 9,11003,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIR WAY SMALL 80MM,12331,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY 10 CM,28846,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY 5CM,28845,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY 8CM,28638,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY 9CM,28639,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY LMA  #3,12647,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
AIRWAY LMA  #4 ADULT,12640,CDM,270,RC,,HCPCS,outpatient,,,$52.39 ,$18.34 ,,$28.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.29 ,75,,,percent of total billed charges,75% of total billed charges,$39.29 ,75,,,percent of total billed charges,75% of total billed charges,$39.29 ,75,,,percent of total billed charges,75% of total billed charges,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.91 ,80,,,percent of total billed charges,80% of total billed charges,$16.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$47.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.22 ,$49.77 ,
AIRWAY LMA #5 ADULT,12641,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
AIRWAY LMA AIRWAY #2.5 CHILD,12646,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
AIRWAY NASOPHARYNGEAL SIZE 22,11416,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY NASOPHARYNGEAL SIZE 26,12888,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY NASOPHARYNGEAL SIZE 30,12889,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY NASOPHARYNGEAL SIZE 34,28847,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAY NASOPHARYNGEAL SIZE 36,28848,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAYS 6 CM,12531,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AIRWAYS 7 CM,12532,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ANESTHESIA CIRCUIT 72 universal,12574,CDM,270,RC,,HCPCS,outpatient,,,$46.50 ,$16.28 ,,$24.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.88 ,75,,,percent of total billed charges,75% of total billed charges,$34.88 ,75,,,percent of total billed charges,75% of total billed charges,$34.88 ,75,,,percent of total billed charges,75% of total billed charges,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.20 ,80,,,percent of total billed charges,80% of total billed charges,$14.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.42 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.07 ,$44.18 ,
ANGIOCATH 14 GA,11988,CDM,270,RC,,HCPCS,outpatient,,,$14.89 ,$5.21 ,,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.90 ,$14.15 ,
ANGIOCATH 16 GA,11989,CDM,270,RC,,HCPCS,outpatient,,,$14.89 ,$5.21 ,,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.90 ,$14.15 ,
ANGIOCATH 18 GA X 1.16,11289,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ANGIOCATH 20 GA,11985,CDM,270,RC,,HCPCS,outpatient,,,$20.92 ,$7.32 ,,$11.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.69 ,75,,,percent of total billed charges,75% of total billed charges,$15.69 ,75,,,percent of total billed charges,75% of total billed charges,$15.69 ,75,,,percent of total billed charges,75% of total billed charges,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.74 ,80,,,percent of total billed charges,80% of total billed charges,$6.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.08 ,$19.87 ,
ANGIOCATH 22 GA,11986,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ANGIOCATH 24 GA,11987,CDM,270,RC,,HCPCS,outpatient,,,$14.89 ,$5.21 ,,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$11.17 ,75,,,percent of total billed charges,75% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges,$4.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.90 ,$14.15 ,
ANGIOCATH 24GA X 0.56,28401,CDM,270,RC,,HCPCS,outpatient,,,$11.40 ,$3.99 ,,$6.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.55 ,75,,,percent of total billed charges,75% of total billed charges,$8.55 ,75,,,percent of total billed charges,75% of total billed charges,$8.55 ,75,,,percent of total billed charges,75% of total billed charges,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.12 ,80,,,percent of total billed charges,80% of total billed charges,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.22 ,$10.83 ,
ANKLE BRACE LARGE RIGHT,11864,CDM,270,RC,,HCPCS,outpatient,,,$88.20 ,$30.87 ,,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$79.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$83.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.20 ,$83.79 ,
ANKLE BRACE LARGE LEFT,12409,CDM,270,RC,,HCPCS,outpatient,,,$88.20 ,$30.87 ,,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$79.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$83.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.20 ,$83.79 ,
ANKLE BRACE MEDIUM RIGHT,12476,CDM,270,RC,,HCPCS,outpatient,,,$92.77 ,$32.47 ,,$49.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.58 ,75,,,percent of total billed charges,75% of total billed charges,$69.58 ,75,,,percent of total billed charges,75% of total billed charges,$69.58 ,75,,,percent of total billed charges,75% of total billed charges,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.22 ,80,,,percent of total billed charges,80% of total billed charges,$29.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.09 ,$88.13 ,
ANKLE TRAINING BRACE SM LEFT,11575,CDM,274,RC,,HCPCS,outpatient,,,$107.54 ,$37.64 ,,$57.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.66 ,75,,,percent of total billed charges,75% of total billed charges,$80.66 ,75,,,percent of total billed charges,75% of total billed charges,$80.66 ,75,,,percent of total billed charges,75% of total billed charges,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.03 ,80,,,percent of total billed charges,80% of total billed charges,$34.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$75.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$96.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$80.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.97 ,$102.16 ,
ANKLE TRAINING BRACE MEDIUM LEFT,12475,CDM,270,RC,,HCPCS,outpatient,,,$111.77 ,$39.12 ,,$59.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.42 ,80,,,percent of total billed charges,80% of total billed charges,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.80 ,$106.18 ,
ANKLE TRAINING BRACE SM RIGHT,12727,CDM,270,RC,,HCPCS,outpatient,,,$111.77 ,$39.12 ,,$59.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$83.83 ,75,,,percent of total billed charges,75% of total billed charges,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.42 ,80,,,percent of total billed charges,80% of total billed charges,$35.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.80 ,$106.18 ,
ANTISEPTIC SPRAY WOUND 8 OZ,30022,CDM,270,RC,,HCPCS,outpatient,,,$44.76 ,$15.67 ,,$23.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.57 ,75,,,percent of total billed charges,75% of total billed charges,$33.57 ,75,,,percent of total billed charges,75% of total billed charges,$33.57 ,75,,,percent of total billed charges,75% of total billed charges,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,80,,,percent of total billed charges,80% of total billed charges,$14.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.28 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.73 ,$42.52 ,
APLIGRAF,28838,CDM,278,RC,,HCPCS,both,,,"$3,885.00 ","$1,359.75 ",,"$2,082.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,082.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,108.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,228.44 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,359.75 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,108.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,719.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,719.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,991.45 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,216.39 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$757.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,204.35 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,496.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$780.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,690.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,108.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$772.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,613.05 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,913.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$780.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,302.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$757.58 ,"$3,690.75 ",
AQUA FLEX HUMIDIFIER,11610,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
AQUA PAK 340,11613,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ARM SLING CHILD,12524,CDM,270,RC,,HCPCS,outpatient,,,$14.23 ,$4.98 ,,$7.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.77 ,$13.52 ,
ARM SLING LARGE,11004,CDM,270,RC,,HCPCS,outpatient,,,$10.97 ,$3.84 ,,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.14 ,$10.42 ,
ARM SLING MEDIUM,12265,CDM,270,RC,,HCPCS,outpatient,,,$10.97 ,$3.84 ,,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.14 ,$10.42 ,
ARM SLING PEDIATRIC,12413,CDM,270,RC,,HCPCS,outpatient,,,$13.07 ,$4.57 ,,$7.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.80 ,75,,,percent of total billed charges,75% of total billed charges,$9.80 ,75,,,percent of total billed charges,75% of total billed charges,$9.80 ,75,,,percent of total billed charges,75% of total billed charges,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.46 ,80,,,percent of total billed charges,80% of total billed charges,$4.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.57 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.55 ,$12.42 ,
ARM SLING SMALL,11385,CDM,270,RC,,HCPCS,outpatient,,,$10.97 ,$3.84 ,,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.14 ,$10.42 ,
ARM SLING X-SMALL,12512,CDM,270,RC,,HCPCS,outpatient,,,$14.23 ,$4.98 ,,$7.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.77 ,$13.52 ,
ARTICULATING TISSUE RELOAD,12707,CDM,270,RC,,HCPCS,outpatient,,,"$1,634.70 ",$572.15 ,,$876.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$876.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,307.76 ",80,,,percent of total billed charges,80% of total billed charges,$516.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$572.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$511.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,307.76 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,144.29 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,144.29 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,258.72 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$511.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$511.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$511.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$511.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$511.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$318.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$506.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,471.23 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$328.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,552.97 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,307.76 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$325.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,520.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,226.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,389.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$318.77 ,"$1,552.97 ",
ARTICULATING VASCULAR RELOAD MED.,12708,CDM,270,RC,,HCPCS,outpatient,,,$823.52 ,$288.23 ,,$441.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$441.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$617.64 ,75,,,percent of total billed charges,75% of total billed charges,$617.64 ,75,,,percent of total billed charges,75% of total billed charges,$617.64 ,75,,,percent of total billed charges,75% of total billed charges,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$658.82 ,80,,,percent of total billed charges,80% of total billed charges,$260.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$288.23 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$658.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$576.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$576.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$634.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$257.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$255.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$741.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$165.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$782.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$658.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$765.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$617.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$617.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$699.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.59 ,$782.34 ,
ARTICULATING VASCULAR RELOAD THIN,12712,CDM,270,RC,,HCPCS,outpatient,,,"$1,533.10 ",$536.59 ,,$821.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$821.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,226.48 ",80,,,percent of total billed charges,80% of total billed charges,$484.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$536.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,226.48 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,073.17 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,073.17 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,180.49 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$480.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$475.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,379.79 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$307.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,456.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,226.48 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$304.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,425.78 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,149.83 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,303.14 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$298.95 ,"$1,456.45 ",
AVITENE 1,12535,CDM,270,RC,,HCPCS,outpatient,,,"$1,545.50 ",$540.93 ,,$828.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$828.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,236.40 ",80,,,percent of total billed charges,80% of total billed charges,$488.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$540.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,236.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,081.85 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,081.85 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,190.04 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$479.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,390.95 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$310.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,468.23 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,236.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$307.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,437.32 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,159.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$310.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,313.68 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$301.37 ,"$1,468.23 ",
Airway 24FR,28911,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Airway 28FR,28912,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Airway 32FR,28913,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BAIR BLANKET,12434,CDM,270,RC,,HCPCS,outpatient,,,$24.85 ,$8.70 ,,$13.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.64 ,75,,,percent of total billed charges,75% of total billed charges,$18.64 ,75,,,percent of total billed charges,75% of total billed charges,$18.64 ,75,,,percent of total billed charges,75% of total billed charges,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.88 ,80,,,percent of total billed charges,80% of total billed charges,$7.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.85 ,$23.61 ,
BAIR FLUID WARMER,12435,CDM,270,RC,,HCPCS,outpatient,,,$94.28 ,$33.00 ,,$50.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.71 ,75,,,percent of total billed charges,75% of total billed charges,$70.71 ,75,,,percent of total billed charges,75% of total billed charges,$70.71 ,75,,,percent of total billed charges,75% of total billed charges,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$75.42 ,80,,,percent of total billed charges,80% of total billed charges,$29.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$84.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$89.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.38 ,$89.57 ,
BAIR PAWS GOWN,12493,CDM,270,RC,,HCPCS,outpatient,,,$71.62 ,$25.07 ,,$38.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.72 ,75,,,percent of total billed charges,75% of total billed charges,$53.72 ,75,,,percent of total billed charges,75% of total billed charges,$53.72 ,75,,,percent of total billed charges,75% of total billed charges,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,80,,,percent of total billed charges,80% of total billed charges,$22.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.97 ,$68.04 ,
BAIR UPPER BODY BLANKET,30109,CDM,270,RC,,HCPCS,outpatient,,,$26.25 ,$9.19 ,,$14.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.00 ,80,,,percent of total billed charges,80% of total billed charges,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.12 ,$24.94 ,
BALLON PACING CATH KIT 5FR,11547,CDM,270,RC,,HCPCS,outpatient,,,$412.00 ,$144.20 ,,$220.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$220.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$309.00 ,75,,,percent of total billed charges,75% of total billed charges,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$329.60 ,80,,,percent of total billed charges,80% of total billed charges,$130.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$144.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$329.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$288.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$317.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$370.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$391.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$329.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$350.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.34 ,$391.40 ,
"BANDAGE COFLEX UNNA CALIMINE SNGL 4"" X 6 YD",30054,CDM,270,RC,,HCPCS,outpatient,,,$38.15 ,$13.35 ,,$20.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.61 ,75,,,percent of total billed charges,75% of total billed charges,$28.61 ,75,,,percent of total billed charges,75% of total billed charges,$28.61 ,75,,,percent of total billed charges,75% of total billed charges,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.52 ,80,,,percent of total billed charges,80% of total billed charges,$12.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.44 ,$36.24 ,
"BANDAGE CONFORM STRETCH 4"" X 75"" STERILE",30048,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BANDAGE DERMACEA STRETCH 4X4 1 YD NS,30019,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BANDAGE FLEX BDG XLG 2X3.75,30080,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BASIC PACK,CDM,CDM,270,RC,,HCPCS,outpatient,,,$162.43 ,$56.85 ,,$87.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.82 ,75,,,percent of total billed charges,75% of total billed charges,$121.82 ,75,,,percent of total billed charges,75% of total billed charges,$121.82 ,75,,,percent of total billed charges,75% of total billed charges,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.94 ,80,,,percent of total billed charges,80% of total billed charges,$51.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.67 ,$154.31 ,
BEAR PAW PED GOWN KIT,28665,CDM,270,RC,,HCPCS,outpatient,,,$55.32 ,$19.36 ,,$29.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.49 ,75,,,percent of total billed charges,75% of total billed charges,$41.49 ,75,,,percent of total billed charges,75% of total billed charges,$41.49 ,75,,,percent of total billed charges,75% of total billed charges,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.26 ,80,,,percent of total billed charges,80% of total billed charges,$17.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.79 ,$52.55 ,
BENZION SWABSTICK,12077,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
BINDER ABD LARGE,12805,CDM,270,RC,,HCPCS,outpatient,,,$60.06 ,$21.02 ,,$32.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.05 ,75,,,percent of total billed charges,75% of total billed charges,$45.05 ,75,,,percent of total billed charges,75% of total billed charges,$45.05 ,75,,,percent of total billed charges,75% of total billed charges,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.05 ,80,,,percent of total billed charges,80% of total billed charges,$18.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.02 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.71 ,$57.06 ,
BINDER ABD MEDIUM,12806,CDM,270,RC,,HCPCS,outpatient,,,$59.27 ,$20.74 ,,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.56 ,$56.31 ,
BINDER ABD SMALL,12807,CDM,270,RC,,HCPCS,outpatient,,,$59.27 ,$20.74 ,,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.56 ,$56.31 ,
BINDER ABD XX LARGE,12808,CDM,270,RC,,HCPCS,outpatient,,,$59.27 ,$20.74 ,,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$44.45 ,75,,,percent of total billed charges,75% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges,$18.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.56 ,$56.31 ,
BIOPSY FORCEPS FB-220U.A,11971,CDM,270,RC,,HCPCS,outpatient,,,$44.26 ,$15.49 ,,$23.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.20 ,75,,,percent of total billed charges,75% of total billed charges,$33.20 ,75,,,percent of total billed charges,75% of total billed charges,$33.20 ,75,,,percent of total billed charges,75% of total billed charges,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,80,,,percent of total billed charges,80% of total billed charges,$14.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.63 ,$42.05 ,
BIOPSY FORCEPS FB230K,12511,CDM,270,RC,,HCPCS,outpatient,,,$71.56 ,$25.05 ,,$38.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.67 ,75,,,percent of total billed charges,75% of total billed charges,$53.67 ,75,,,percent of total billed charges,75% of total billed charges,$53.67 ,75,,,percent of total billed charges,75% of total billed charges,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.25 ,80,,,percent of total billed charges,80% of total billed charges,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.95 ,$67.98 ,
BIOPSY FORCEPS FD210U,12528,CDM,270,RC,,HCPCS,outpatient,,,$102.12 ,$35.74 ,,$54.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.59 ,75,,,percent of total billed charges,75% of total billed charges,$76.59 ,75,,,percent of total billed charges,75% of total billed charges,$76.59 ,75,,,percent of total billed charges,75% of total billed charges,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.70 ,80,,,percent of total billed charges,80% of total billed charges,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.01 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.91 ,$97.01 ,
BIOPSY PUNCH STERILE DISP 4MM,30035,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BIOPSY PUNCH STERILE DISP 3MM,30034,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BIOPSY VALVE BIOSHIELD,12802,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BIOPSY VALVE SINGLE USE,12197,CDM,270,RC,,HCPCS,outpatient,,,$61.29 ,$21.45 ,,$32.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.03 ,80,,,percent of total billed charges,80% of total billed charges,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.95 ,$58.23 ,
BIPAP CIRCUIT,17056,CDM,270,RC,,HCPCS,outpatient,,,$22.26 ,$7.79 ,,$11.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.70 ,75,,,percent of total billed charges,75% of total billed charges,$16.70 ,75,,,percent of total billed charges,75% of total billed charges,$16.70 ,75,,,percent of total billed charges,75% of total billed charges,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.81 ,80,,,percent of total billed charges,80% of total billed charges,$7.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.34 ,$21.15 ,
BIPOLAR HEMOSTASIS PROBE,12530,CDM,270,RC,,HCPCS,outpatient,,,$650.00 ,$227.50 ,,$348.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$348.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$487.50 ,75,,,percent of total billed charges,75% of total billed charges,$487.50 ,75,,,percent of total billed charges,75% of total billed charges,$487.50 ,75,,,percent of total billed charges,75% of total billed charges,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$520.00 ,80,,,percent of total billed charges,80% of total billed charges,$205.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$227.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$520.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$455.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$455.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$500.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$203.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$201.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$585.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$130.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$617.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$520.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$129.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$604.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$487.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$487.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$487.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$552.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.75 ,$617.50 ,
BLADE CLIPPER UNIVERSAL GRAY,30075,CDM,270,RC,,HCPCS,outpatient,,,$22.53 ,$7.89 ,,$12.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.90 ,75,,,percent of total billed charges,75% of total billed charges,$16.90 ,75,,,percent of total billed charges,75% of total billed charges,$16.90 ,75,,,percent of total billed charges,75% of total billed charges,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.02 ,80,,,percent of total billed charges,80% of total billed charges,$7.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.28 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.39 ,$21.40 ,
BLADELESS TROCAR 12MM/150M,12698,CDM,270,RC,,HCPCS,outpatient,,,$137.75 ,$48.21 ,,$73.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$73.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.20 ,80,,,percent of total billed charges,80% of total billed charges,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$123.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,$130.86 ,
BLADELESS TROCAR 12MM/100M,12538,CDM,270,RC,,HCPCS,outpatient,,,$200.21 ,$70.07 ,,$107.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$150.16 ,75,,,percent of total billed charges,75% of total billed charges,$150.16 ,75,,,percent of total billed charges,75% of total billed charges,$150.16 ,75,,,percent of total billed charges,75% of total billed charges,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$160.17 ,80,,,percent of total billed charges,80% of total billed charges,$63.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$140.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$180.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$150.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$150.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.04 ,$190.20 ,
BLADELESS TROCAR 5MM/150M,12697,CDM,270,RC,,HCPCS,outpatient,,,$109.25 ,$38.24 ,,$58.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.94 ,75,,,percent of total billed charges,75% of total billed charges,$81.94 ,75,,,percent of total billed charges,75% of total billed charges,$81.94 ,75,,,percent of total billed charges,75% of total billed charges,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.40 ,80,,,percent of total billed charges,80% of total billed charges,$34.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.30 ,$103.79 ,
BLADELESS TROCAR 5MM/100M,12537,CDM,270,RC,,HCPCS,outpatient,,,$142.50 ,$49.88 ,,$76.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.88 ,75,,,percent of total billed charges,75% of total billed charges,$106.88 ,75,,,percent of total billed charges,75% of total billed charges,$106.88 ,75,,,percent of total billed charges,75% of total billed charges,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.88 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$99.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$109.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$128.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$106.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$121.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.79 ,$135.38 ,
BLADELESS TROCAR HANDLED,12545,CDM,270,RC,,HCPCS,outpatient,,,$256.53 ,$89.79 ,,$137.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$137.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.40 ,75,,,percent of total billed charges,75% of total billed charges,$192.40 ,75,,,percent of total billed charges,75% of total billed charges,$192.40 ,75,,,percent of total billed charges,75% of total billed charges,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.22 ,80,,,percent of total billed charges,80% of total billed charges,$81.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$197.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$230.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$243.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$192.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.02 ,$243.70 ,
BLAKE DRAIN FLAT 1/4,12700,CDM,270,RC,,HCPCS,outpatient,,,$97.02 ,$33.96 ,,$52.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$52.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.77 ,75,,,percent of total billed charges,75% of total billed charges,$72.77 ,75,,,percent of total billed charges,75% of total billed charges,$72.77 ,75,,,percent of total billed charges,75% of total billed charges,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.62 ,80,,,percent of total billed charges,80% of total billed charges,$30.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$87.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.92 ,$92.17 ,
BLAKE DRAIN FLAT 3/8,12701,CDM,270,RC,,HCPCS,outpatient,,,$68.69 ,$24.04 ,,$36.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.52 ,75,,,percent of total billed charges,75% of total billed charges,$51.52 ,75,,,percent of total billed charges,75% of total billed charges,$51.52 ,75,,,percent of total billed charges,75% of total billed charges,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.95 ,80,,,percent of total billed charges,80% of total billed charges,$21.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$61.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$65.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$51.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,$65.26 ,
BLOOD SAMPLE KITS,12001,CDM,300,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.00 ,75,,,percent of total billed charges,75% of total billed charges,$5.00 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BLOOD SET,11013,CDM,270,RC,,HCPCS,outpatient,,,$24.50 ,$8.58 ,,$13.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.60 ,80,,,percent of total billed charges,80% of total billed charges,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.78 ,$23.28 ,
BLUE RHINO TRACH INTRO TRAY G57708,3056,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BONE INJECTION GUN ADULT,28413,CDM,270,RC,,HCPCS,outpatient,,,$325.93 ,$114.08 ,,$174.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.74 ,80,,,percent of total billed charges,80% of total billed charges,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$250.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.56 ,$309.63 ,
BONE INJECTION GUN PEDIATRIC,28414,CDM,270,RC,,HCPCS,outpatient,,,$325.93 ,$114.08 ,,$174.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$244.45 ,75,,,percent of total billed charges,75% of total billed charges,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.74 ,80,,,percent of total billed charges,80% of total billed charges,$103.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$250.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.56 ,$309.63 ,
BONE WAX,11015,CDM,270,RC,,HCPCS,outpatient,,,$133.38 ,$46.68 ,,$71.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.04 ,75,,,percent of total billed charges,75% of total billed charges,$100.04 ,75,,,percent of total billed charges,75% of total billed charges,$100.04 ,75,,,percent of total billed charges,75% of total billed charges,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$106.70 ,80,,,percent of total billed charges,80% of total billed charges,$42.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$106.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$93.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$120.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$100.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$113.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.01 ,$126.71 ,
BORDERED ADH ISLAND DRESSING 4 X 4' W/ 2.5X2.5 PAD,30073,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BORDERED ADH ISLAND DRESSING 4 X 10' W/ 2X8 PAD,30023,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BORDERED GAUZE ADH ISLAND DRESSING 6X6,30024,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
BP CUFF ADULT REG W/BULB & GAUGE ISOLATION,11281,CDM,270,RC,,HCPCS,outpatient,,,$138.03 ,$48.31 ,,$73.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$73.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.52 ,75,,,percent of total billed charges,75% of total billed charges,$103.52 ,75,,,percent of total billed charges,75% of total billed charges,$103.52 ,75,,,percent of total billed charges,75% of total billed charges,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.42 ,80,,,percent of total billed charges,80% of total billed charges,$43.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.92 ,$131.13 ,
BREATHING BAG PED 2 LTR,28676,CDM,270,RC,,HCPCS,outpatient,,,$11.01 ,$3.85 ,,$5.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.26 ,75,,,percent of total billed charges,75% of total billed charges,$8.26 ,75,,,percent of total billed charges,75% of total billed charges,$8.26 ,75,,,percent of total billed charges,75% of total billed charges,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.81 ,80,,,percent of total billed charges,80% of total billed charges,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.15 ,$10.46 ,
BREATHING CIRCUIT PEDS,11342,CDM,270,RC,,HCPCS,outpatient,,,$22.79 ,$7.98 ,,$12.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.09 ,75,,,percent of total billed charges,75% of total billed charges,$17.09 ,75,,,percent of total billed charges,75% of total billed charges,$17.09 ,75,,,percent of total billed charges,75% of total billed charges,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,80,,,percent of total billed charges,80% of total billed charges,$7.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.44 ,$21.65 ,
BREATHING CIRCUIT KING SYSTEMS,12822,CDM,270,RC,,HCPCS,outpatient,,,$40.45 ,$14.16 ,,$21.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.34 ,75,,,percent of total billed charges,75% of total billed charges,$30.34 ,75,,,percent of total billed charges,75% of total billed charges,$30.34 ,75,,,percent of total billed charges,75% of total billed charges,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.36 ,80,,,percent of total billed charges,80% of total billed charges,$12.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$36.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.89 ,$38.43 ,
BUFFALO FILTER TUBING,28626,CDM,270,RC,,HCPCS,outpatient,,,$24.50 ,$8.58 ,,$13.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$18.38 ,75,,,percent of total billed charges,75% of total billed charges,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.60 ,80,,,percent of total billed charges,80% of total billed charges,$7.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.78 ,$23.28 ,
BURETROL ADD ON SET,11809,CDM,270,RC,,HCPCS,outpatient,,,$26.13 ,$9.15 ,,$14.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.60 ,75,,,percent of total billed charges,75% of total billed charges,$19.60 ,75,,,percent of total billed charges,75% of total billed charges,$19.60 ,75,,,percent of total billed charges,75% of total billed charges,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.90 ,80,,,percent of total billed charges,80% of total billed charges,$8.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.10 ,$24.82 ,
BUTTON REPL GAST 18 FR 3.4 CM,11370,CDM,270,RC,,HCPCS,outpatient,,,"$1,543.50 ",$540.23 ,,$827.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$827.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,234.80 ",80,,,percent of total billed charges,80% of total billed charges,$488.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$540.23 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,234.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,080.45 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,080.45 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,188.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$483.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$478.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,389.15 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$309.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,466.33 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,234.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$307.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,435.46 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,157.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,311.98 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.98 ,"$1,466.33 ",
BUTTON REPL GAST 24 FR 4.4 CM,12753,CDM,270,RC,,HCPCS,outpatient,,,$580.00 ,$203.00 ,,$310.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$310.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$435.00 ,75,,,percent of total billed charges,75% of total billed charges,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$464.00 ,80,,,percent of total billed charges,80% of total billed charges,$183.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$203.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$406.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$406.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$446.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$179.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$522.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$116.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$551.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$115.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$539.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$435.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$435.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$435.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$493.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.10 ,$551.00 ,
Band Ligator Super 7,20268,CDM,270,RC,,HCPCS,outpatient,,,$964.69 ,$337.64 ,,$517.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$517.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$723.52 ,75,,,percent of total billed charges,75% of total billed charges,$723.52 ,75,,,percent of total billed charges,75% of total billed charges,$723.52 ,75,,,percent of total billed charges,75% of total billed charges,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.75 ,80,,,percent of total billed charges,80% of total billed charges,$305.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$337.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$771.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$675.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$675.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$742.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$299.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$868.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$193.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$916.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$771.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$897.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$723.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$723.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$193.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$819.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$188.11 ,$916.46 ,
Bandage Net Tubular size 2,12371,CDM,270,RC,,HCPCS,outpatient,,,$55.49 ,$19.42 ,,$29.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.62 ,75,,,percent of total billed charges,75% of total billed charges,$41.62 ,75,,,percent of total billed charges,75% of total billed charges,$41.62 ,75,,,percent of total billed charges,75% of total billed charges,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.39 ,80,,,percent of total billed charges,80% of total billed charges,$17.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.82 ,$52.72 ,
Biopatch Foam Disc,20262,CDM,270,RC,,HCPCS,outpatient,,,$27.18 ,$9.51 ,,$14.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.39 ,75,,,percent of total billed charges,75% of total billed charges,$20.39 ,75,,,percent of total billed charges,75% of total billed charges,$20.39 ,75,,,percent of total billed charges,75% of total billed charges,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.74 ,80,,,percent of total billed charges,80% of total billed charges,$8.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.30 ,$25.82 ,
Blades Dermatome Zimmer,11602,CDM,270,RC,,HCPCS,outpatient,,,$301.75 ,$105.61 ,,$161.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$161.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$226.31 ,75,,,percent of total billed charges,75% of total billed charges,$226.31 ,75,,,percent of total billed charges,75% of total billed charges,$226.31 ,75,,,percent of total billed charges,75% of total billed charges,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$241.40 ,80,,,percent of total billed charges,80% of total billed charges,$95.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$105.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$211.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$93.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$271.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$286.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$226.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$226.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$226.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$256.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.84 ,$286.66 ,
CANNULA INFANT,11794,CDM,270,RC,,HCPCS,outpatient,,,$22.71 ,$7.95 ,,$12.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.03 ,75,,,percent of total billed charges,75% of total billed charges,$17.03 ,75,,,percent of total billed charges,75% of total billed charges,$17.03 ,75,,,percent of total billed charges,75% of total billed charges,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,80,,,percent of total billed charges,80% of total billed charges,$7.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.43 ,$21.57 ,
CANNULAS NASAL ADULT,12010,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAPNOGRAPHY WITHOUT VENT,28667,CDM,270,RC,,HCPCS,outpatient,,,$21.93 ,$7.68 ,,$11.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.45 ,75,,,percent of total billed charges,75% of total billed charges,$16.45 ,75,,,percent of total billed charges,75% of total billed charges,$16.45 ,75,,,percent of total billed charges,75% of total billed charges,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.54 ,80,,,percent of total billed charges,80% of total billed charges,$6.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.28 ,$20.83 ,
CAST PADDING 2,11584,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAST PADDING 3,11585,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAST PADDING 4,11586,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAST PADDING 6,11587,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAST SHOE LARGE,12268,CDM,270,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
CAST SHOE MEDIUM,12267,CDM,270,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
CAST SHOE SMALL,11899,CDM,270,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
CATH BAKER JEJUNOSTOMY 12 FR,20269,CDM,270,RC,,HCPCS,outpatient,,,"$1,048.85 ",$367.10 ,,$562.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$562.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$786.64 ,75,,,percent of total billed charges,75% of total billed charges,$786.64 ,75,,,percent of total billed charges,75% of total billed charges,$786.64 ,75,,,percent of total billed charges,75% of total billed charges,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$839.08 ,80,,,percent of total billed charges,80% of total billed charges,$331.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$367.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$839.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$734.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$734.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$807.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$325.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$943.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$210.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$996.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$839.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$208.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$975.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$786.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$786.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$786.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$210.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$891.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.53 ,$996.41 ,
CATH CONE TIP 5 FR  024605,12780,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH CONE TIP LEFT 6-10 FR  024606,12713,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH CONE TIP RIGHT 8-14 FR  024608,12779,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH FLEX TIP LEFT 5 FR,12721,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH FLEX TIP LEFT 6 FR,12722,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH FLEX TIP RIGHT 5 FR,12723,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH FLEX TIP RIGHT 6 FR,12724,CDM,270,RC,,HCPCS,outpatient,,,$45.15 ,$15.80 ,,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$33.86 ,75,,,percent of total billed charges,75% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges,$14.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,$42.89 ,
CATH FOLEY 16FR 0165L16,93046,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH FOLEY 2-WAY 30CC BAL 24FR,93068,CDM,272,RC,,HCPCS,outpatient,,,$46.01 ,$16.10 ,,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.81 ,80,,,percent of total billed charges,80% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.97 ,$43.71 ,
CATH FOLEY 20FR 0165L20,93047,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH FOLEY 22FR 0165L22,93049,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH FOLEY 3 WAY 24 FR,93098,CDM,272,RC,,HCPCS,outpatient,,,$45.96 ,$16.09 ,,$24.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.47 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,75,,,percent of total billed charges,75% of total billed charges,$34.47 ,75,,,percent of total billed charges,75% of total billed charges,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.77 ,80,,,percent of total billed charges,80% of total billed charges,$14.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.09 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.96 ,$43.66 ,
CATH FOLEY 3-WAY 22FR 0167V22S,93045,CDM,272,RC,,HCPCS,outpatient,,,$48.27 ,$16.89 ,,$25.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.20 ,75,,,percent of total billed charges,75% of total billed charges,$36.20 ,75,,,percent of total billed charges,75% of total billed charges,$36.20 ,75,,,percent of total billed charges,75% of total billed charges,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.62 ,80,,,percent of total billed charges,80% of total billed charges,$15.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.41 ,$45.86 ,
CATH FOLEY 3-WAY 30 ML BAL 26 FR,93069,CDM,272,RC,,HCPCS,outpatient,,,$46.11 ,$16.14 ,,$24.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.58 ,75,,,percent of total billed charges,75% of total billed charges,$34.58 ,75,,,percent of total billed charges,75% of total billed charges,$34.58 ,75,,,percent of total billed charges,75% of total billed charges,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.89 ,80,,,percent of total billed charges,80% of total billed charges,$14.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.99 ,$43.80 ,
CATH KIT MULTI LUMEN,11424,CDM,270,RC,,HCPCS,outpatient,,,$512.66 ,$179.43 ,,$274.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$274.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$384.50 ,75,,,percent of total billed charges,75% of total billed charges,$384.50 ,75,,,percent of total billed charges,75% of total billed charges,$384.50 ,75,,,percent of total billed charges,75% of total billed charges,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$410.13 ,80,,,percent of total billed charges,80% of total billed charges,$162.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$179.43 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$410.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$358.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$358.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$394.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$158.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$461.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$487.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$410.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$476.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$384.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$384.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$384.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$435.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.97 ,$487.03 ,
CATH KIT RADIAL ARTERY,11826,CDM,270,RC,,HCPCS,outpatient,,,$109.73 ,$38.41 ,,$58.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.30 ,75,,,percent of total billed charges,75% of total billed charges,$82.30 ,75,,,percent of total billed charges,75% of total billed charges,$82.30 ,75,,,percent of total billed charges,75% of total billed charges,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.78 ,80,,,percent of total billed charges,80% of total billed charges,$34.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.40 ,$104.24 ,
CATH RED RUBBER  16 FR.,11034,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH RED RUBBER 12 FR,12728,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH RED RUBBER 14 FR,12729,CDM,270,RC,,HCPCS,outpatient,,,$20.14 ,$7.05 ,,$10.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.11 ,75,,,percent of total billed charges,75% of total billed charges,$15.11 ,75,,,percent of total billed charges,75% of total billed charges,$15.11 ,75,,,percent of total billed charges,75% of total billed charges,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.11 ,80,,,percent of total billed charges,80% of total billed charges,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.13 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.93 ,$19.13 ,
CATH SINGLE LUMEN 14 GA,12786,CDM,270,RC,,HCPCS,outpatient,,,$108.44 ,$37.95 ,,$58.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.33 ,75,,,percent of total billed charges,75% of total billed charges,$81.33 ,75,,,percent of total billed charges,75% of total billed charges,$81.33 ,75,,,percent of total billed charges,75% of total billed charges,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.75 ,80,,,percent of total billed charges,80% of total billed charges,$34.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$75.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.15 ,$103.02 ,
CATH SOLO 2  POWER PICC 5FR 3295108FD - DO NOT REORDER,93051,CDM,272,RC,,HCPCS,outpatient,,,"$1,256.12 ",$439.64 ,,$673.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$673.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$942.09 ,75,,,percent of total billed charges,75% of total billed charges,$942.09 ,75,,,percent of total billed charges,75% of total billed charges,$942.09 ,75,,,percent of total billed charges,75% of total billed charges,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,004.90 ",80,,,percent of total billed charges,80% of total billed charges,$397.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$439.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,004.90 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$879.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$879.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$967.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$389.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,130.51 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$252.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,193.31 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,004.90 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$249.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,168.19 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$942.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$942.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$942.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$252.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,067.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$244.94 ,"$1,193.31 ",
CATH SPIRAL TIP 5 FR,11298,CDM,270,RC,,HCPCS,outpatient,,,$46.20 ,$16.17 ,,$24.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.65 ,75,,,percent of total billed charges,75% of total billed charges,$34.65 ,75,,,percent of total billed charges,75% of total billed charges,$34.65 ,75,,,percent of total billed charges,75% of total billed charges,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.96 ,80,,,percent of total billed charges,80% of total billed charges,$14.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.01 ,$43.89 ,
CATH STRAP,11078,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 10 FR,12085,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 12 FR,12086,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 14 FR,12087,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 16 FR,12088,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 18 FR,12089,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 6 FR,12083,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION 8 FR,12084,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH SUCTION W/ VALVE 8FR,93100,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CATH TROCAR 10 FR,12461,CDM,270,RC,,HCPCS,outpatient,,,$129.95 ,$45.48 ,,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$116.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.34 ,$123.45 ,
CATH TROCAR 12 FR,12462,CDM,270,RC,,HCPCS,outpatient,,,$76.20 ,$26.67 ,,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$68.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.86 ,$72.39 ,
CATH TROCAR 16 FR,12463,CDM,270,RC,,HCPCS,outpatient,,,$76.20 ,$26.67 ,,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$68.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.86 ,$72.39 ,
CATH TROCAR 24 FR,12465,CDM,270,RC,,HCPCS,outpatient,,,$129.95 ,$45.48 ,,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$116.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.34 ,$123.45 ,
CATH TROCAR 28 FR,12466,CDM,270,RC,,HCPCS,outpatient,,,$129.95 ,$45.48 ,,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$116.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.34 ,$123.45 ,
CATH TROCAR 32 FR,12467,CDM,270,RC,,HCPCS,outpatient,,,$76.20 ,$26.67 ,,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$57.15 ,75,,,percent of total billed charges,75% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges,$24.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$68.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.86 ,$72.39 ,
CATH TROCAR 8 FR,12460,CDM,270,RC,,HCPCS,outpatient,,,$129.95 ,$45.48 ,,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$97.46 ,75,,,percent of total billed charges,75% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges,$41.09 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$116.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.34 ,$123.45 ,
CATH TWIN MULTI LUMEN 18 GA,11414,CDM,270,RC,,HCPCS,outpatient,,,$54.60 ,$19.11 ,,$29.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.95 ,75,,,percent of total billed charges,75% of total billed charges,$40.95 ,75,,,percent of total billed charges,75% of total billed charges,$40.95 ,75,,,percent of total billed charges,75% of total billed charges,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.68 ,80,,,percent of total billed charges,80% of total billed charges,$17.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.65 ,$51.87 ,
CATH UMBILICAL VESSEL 8FR,11229,CDM,272,RC,,HCPCS,outpatient,,,$145.88 ,$51.06 ,,$78.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$109.41 ,75,,,percent of total billed charges,75% of total billed charges,$109.41 ,75,,,percent of total billed charges,75% of total billed charges,$109.41 ,75,,,percent of total billed charges,75% of total billed charges,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.70 ,80,,,percent of total billed charges,80% of total billed charges,$46.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$51.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$45.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$131.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$109.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$124.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.45 ,$138.59 ,
CATH tiemann coude tip 20ga,NS117,CDM,272,RC,,HCPCS,outpatient,,,$58.44 ,$20.45 ,,$31.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.83 ,75,,,percent of total billed charges,75% of total billed charges,$43.83 ,75,,,percent of total billed charges,75% of total billed charges,$43.83 ,75,,,percent of total billed charges,75% of total billed charges,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.75 ,80,,,percent of total billed charges,80% of total billed charges,$18.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.40 ,$55.52 ,
CATHETER TEXAS MALE,11163,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CAUTERY FINE TIP DIAGNOSTIC HI-TEMP  ESCT001,11379,CDM,270,RC,,HCPCS,outpatient,,,$48.50 ,$16.98 ,,$26.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.38 ,75,,,percent of total billed charges,75% of total billed charges,$36.38 ,75,,,percent of total billed charges,75% of total billed charges,$36.38 ,75,,,percent of total billed charges,75% of total billed charges,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.80 ,80,,,percent of total billed charges,80% of total billed charges,$15.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.65 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.46 ,$46.08 ,
CENTRAL LINE DRESSING,11792,CDM,270,RC,,HCPCS,outpatient,,,$44.00 ,$15.40 ,,$23.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$33.00 ,75,,,percent of total billed charges,75% of total billed charges,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.20 ,80,,,percent of total billed charges,80% of total billed charges,$13.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.58 ,$41.80 ,
CERVICAL COLLAR HARD LARGE,11036,CDM,274,RC,,HCPCS,outpatient,,,$214.22 ,$74.98 ,,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$192.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$203.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.77 ,$203.51 ,
CERVICAL COLLAR HARD MED.,12340,CDM,274,RC,,HCPCS,outpatient,,,$214.22 ,$74.98 ,,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$192.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$203.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.77 ,$203.51 ,
CERVICAL COLLAR HARD SMALL,12341,CDM,274,RC,,HCPCS,outpatient,,,$214.22 ,$74.98 ,,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$114.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$160.67 ,75,,,percent of total billed charges,75% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges,$67.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$149.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$192.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$203.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.77 ,$203.51 ,
CHOLANGIOGRAM KIT,11038,CDM,272,RC,,HCPCS,outpatient,,,$520.00 ,$182.00 ,,$278.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$278.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$390.00 ,75,,,percent of total billed charges,75% of total billed charges,$390.00 ,75,,,percent of total billed charges,75% of total billed charges,$390.00 ,75,,,percent of total billed charges,75% of total billed charges,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$416.00 ,80,,,percent of total billed charges,80% of total billed charges,$164.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$182.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$416.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$364.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$400.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$162.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$161.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$468.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$104.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$494.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$416.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$103.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$483.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$390.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$390.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$390.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$442.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.40 ,$494.00 ,
CIDEX OPA,CDM,CDM,270,RC,,HCPCS,outpatient,,,$92.35 ,$32.32 ,,$49.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.26 ,75,,,percent of total billed charges,75% of total billed charges,$69.26 ,75,,,percent of total billed charges,75% of total billed charges,$69.26 ,75,,,percent of total billed charges,75% of total billed charges,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.88 ,80,,,percent of total billed charges,80% of total billed charges,$29.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.01 ,$87.73 ,
CLAMP FOR 4 POUCH,12343,CDM,274,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CLAVICAL BRACE LARGE,11040,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLAVICAL BRACE MEDIUM,12344,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLAVICAL BRACE SMALL,12345,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLAVICAL BRACE X-LARGE,12346,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLAVICAL SHOULDER BRACE INFANT,11652,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLAVICAL SHOULDER BRACE PED,12828,CDM,274,RC,,HCPCS,outpatient,,,$21.52 ,$7.53 ,,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.14 ,75,,,percent of total billed charges,75% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges,$6.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.37 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.20 ,$20.44 ,
CLEANSER SKIN FOAM SOOTH & COOL 4 OZ,30066,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CLIPPER SURGICAL 3M (9661),30050,CDM,270,RC,,HCPCS,outpatient,,,$241.59 ,$84.56 ,,$129.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$129.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$181.19 ,75,,,percent of total billed charges,75% of total billed charges,$181.19 ,75,,,percent of total billed charges,75% of total billed charges,$181.19 ,75,,,percent of total billed charges,75% of total billed charges,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$193.27 ,80,,,percent of total billed charges,80% of total billed charges,$76.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$84.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$169.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$186.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$74.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$217.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$229.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$181.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$181.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$181.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.11 ,$229.51 ,
CO2 DISP TUBE,11760,CDM,270,RC,,HCPCS,outpatient,,,$58.91 ,$20.62 ,,$31.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.18 ,75,,,percent of total billed charges,75% of total billed charges,$44.18 ,75,,,percent of total billed charges,75% of total billed charges,$44.18 ,75,,,percent of total billed charges,75% of total billed charges,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.13 ,80,,,percent of total billed charges,80% of total billed charges,$18.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.07 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.49 ,$55.96 ,
COAGRASPER HEMOSTATIC GRASPER,12796,CDM,270,RC,,HCPCS,outpatient,,,$756.76 ,$264.87 ,,$405.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$405.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$567.57 ,75,,,percent of total billed charges,75% of total billed charges,$567.57 ,75,,,percent of total billed charges,75% of total billed charges,$567.57 ,75,,,percent of total billed charges,75% of total billed charges,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$605.41 ,80,,,percent of total billed charges,80% of total billed charges,$239.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$264.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$605.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$529.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$529.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$582.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$236.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$236.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$234.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$681.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$151.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$718.92 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$605.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$703.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$567.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$567.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$567.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$643.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.57 ,$718.92 ,
COAXIAL SHEATH 12 X6 13.8 CM,28706,CDM,270,RC,,HCPCS,outpatient,,,$89.57 ,$31.35 ,,$48.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.18 ,75,,,percent of total billed charges,75% of total billed charges,$67.18 ,75,,,percent of total billed charges,75% of total billed charges,$67.18 ,75,,,percent of total billed charges,75% of total billed charges,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.66 ,80,,,percent of total billed charges,80% of total billed charges,$28.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$85.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$67.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.47 ,$85.09 ,
COBAN 2,11530,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COBAN 4,11340,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COFLEX TLC 2- LAYER COMP SYSTEM,30077,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
COLD PACK INSTANT,11948,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
COLLAR CERVICAL SZ SM LONG,93073,CDM,274,RC,,HCPCS,outpatient,,,$13.81 ,$4.83 ,,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.69 ,$13.12 ,
COLOSTOMY WOUND CARE KIT 2 1/4,12196,CDM,270,RC,,HCPCS,outpatient,,,$26.46 ,$9.26 ,,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.16 ,$25.14 ,
COMFORT CARE PAD LARGE,12622,CDM,270,RC,,HCPCS,outpatient,,,$998.00 ,$349.30 ,,$534.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$534.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.40 ,80,,,percent of total billed charges,80% of total billed charges,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$349.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$768.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$309.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$898.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$200.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$948.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$928.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$200.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$194.61 ,$948.10 ,
COMFORT CARE PAD SMALL,12621,CDM,270,RC,,HCPCS,outpatient,,,$998.00 ,$349.30 ,,$534.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$534.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$748.50 ,75,,,percent of total billed charges,75% of total billed charges,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$798.40 ,80,,,percent of total billed charges,80% of total billed charges,$315.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$349.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$798.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$698.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$768.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$312.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$309.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$898.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$200.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$948.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$798.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$928.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$748.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$200.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$848.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$194.61 ,$948.10 ,
CONT. FLO SET,11601,CDM,270,RC,,HCPCS,outpatient,,,$13.76 ,$4.82 ,,$7.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.32 ,75,,,percent of total billed charges,75% of total billed charges,$10.32 ,75,,,percent of total billed charges,75% of total billed charges,$10.32 ,75,,,percent of total billed charges,75% of total billed charges,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.01 ,80,,,percent of total billed charges,80% of total billed charges,$4.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.68 ,$13.07 ,
CONTINU-FLO SET 0.2 MICRON 60 DROP (2C6572),11592,CDM,270,RC,,HCPCS,outpatient,,,$31.76 ,$11.12 ,,$17.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.82 ,75,,,percent of total billed charges,75% of total billed charges,$23.82 ,75,,,percent of total billed charges,75% of total billed charges,$23.82 ,75,,,percent of total billed charges,75% of total billed charges,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.41 ,80,,,percent of total billed charges,80% of total billed charges,$10.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.19 ,$30.17 ,
CORRUGATED TUBING 72',90571,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
COTTON TIP APPLICATOR,12090,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
CUROS CONNECTOR CAPS,28573,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
CYTOLOGY BRUSH DISP. FOR BRONC SCOPE,11972,CDM,270,RC,,HCPCS,outpatient,,,$83.51 ,$29.23 ,,$44.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.63 ,75,,,percent of total billed charges,75% of total billed charges,$62.63 ,75,,,percent of total billed charges,75% of total billed charges,$62.63 ,75,,,percent of total billed charges,75% of total billed charges,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.81 ,80,,,percent of total billed charges,80% of total billed charges,$26.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.23 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$75.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$62.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.28 ,$79.33 ,
Cannula ETCO2 w/7 gas,30095,CDM,270,RC,,HCPCS,outpatient,,,$12.30 ,$4.31 ,,$6.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.23 ,75,,,percent of total billed charges,75% of total billed charges,$9.23 ,75,,,percent of total billed charges,75% of total billed charges,$9.23 ,75,,,percent of total billed charges,75% of total billed charges,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,80,,,percent of total billed charges,80% of total billed charges,$3.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.69 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.40 ,$11.69 ,
Cannula High Flow Large,20319,CDM,270,RC,,HCPCS,outpatient,,,$99.75 ,$34.91 ,,$53.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.80 ,80,,,percent of total billed charges,80% of total billed charges,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$89.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.45 ,$94.76 ,
Cannula High Flow Med,30256,CDM,270,RC,,HCPCS,outpatient,,,$99.75 ,$34.91 ,,$53.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$74.81 ,75,,,percent of total billed charges,75% of total billed charges,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.80 ,80,,,percent of total billed charges,80% of total billed charges,$31.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$89.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.45 ,$94.76 ,
Cath 7 fr Hohn Dual Lumen,28643,CDM,270,RC,,HCPCS,outpatient,,,$899.36 ,$314.78 ,,$482.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$482.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$674.52 ,75,,,percent of total billed charges,75% of total billed charges,$674.52 ,75,,,percent of total billed charges,75% of total billed charges,$674.52 ,75,,,percent of total billed charges,75% of total billed charges,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$719.49 ,80,,,percent of total billed charges,80% of total billed charges,$284.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$314.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$719.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$629.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$629.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$692.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$281.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$278.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$809.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$180.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$854.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$719.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$178.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$836.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$674.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$674.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$674.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$180.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$764.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$175.38 ,$854.39 ,
Circuit 22mm Non-Heated,11018,CDM,272,RC,,HCPCS,outpatient,,,$143.01 ,$50.05 ,,$76.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.26 ,75,,,percent of total billed charges,75% of total billed charges,$107.26 ,75,,,percent of total billed charges,75% of total billed charges,$107.26 ,75,,,percent of total billed charges,75% of total billed charges,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.41 ,80,,,percent of total billed charges,80% of total billed charges,$45.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$128.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$107.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$121.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.89 ,$135.86 ,
"Circuit,High Flow Heated Adult",30257,CDM,270,RC,,HCPCS,outpatient,,,$58.54 ,$20.49 ,,$31.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.91 ,75,,,percent of total billed charges,75% of total billed charges,$43.91 ,75,,,percent of total billed charges,75% of total billed charges,$43.91 ,75,,,percent of total billed charges,75% of total billed charges,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.83 ,80,,,percent of total billed charges,80% of total billed charges,$18.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.42 ,$55.61 ,
"Coban 2 Layer Lite 4""",11762,CDM,270,RC,,HCPCS,outpatient,,,$55.75 ,$19.51 ,,$29.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.81 ,75,,,percent of total billed charges,75% of total billed charges,$41.81 ,75,,,percent of total billed charges,75% of total billed charges,$41.81 ,75,,,percent of total billed charges,75% of total billed charges,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.60 ,80,,,percent of total billed charges,80% of total billed charges,$17.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$50.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.87 ,$52.96 ,
Collagen Gel Stimulen,30206,CDM,270,RC,,HCPCS,outpatient,,,$22.05 ,$7.72 ,,$11.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.64 ,80,,,percent of total billed charges,80% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.30 ,$20.95 ,
Collagen Powder Strimulen ST9501,30205,CDM,270,RC,,HCPCS,outpatient,,,$65.69 ,$22.99 ,,$35.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.27 ,75,,,percent of total billed charges,75% of total billed charges,$49.27 ,75,,,percent of total billed charges,75% of total billed charges,$49.27 ,75,,,percent of total billed charges,75% of total billed charges,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.55 ,80,,,percent of total billed charges,80% of total billed charges,$20.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$59.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.81 ,$62.41 ,
Curad Pet. Gauze Dressing,30096,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DEBRIDEMENT TRAY W/SAFETY SCAPEL LF,30081,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
DENALI FILTER VEMERAL,28642,CDM,270,RC,,HCPCS,outpatient,,,"$4,500.00 ","$1,575.00 ",,"$2,412.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,412.00 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,600.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,422.90 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,575.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,600.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,150.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,150.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,465.00 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,408.95 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$877.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,395.00 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,050.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$903.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,275.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,600.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$895.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,185.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,375.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$903.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,825.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$895.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$877.50 ,"$4,275.00 ",
DERMABOND MINI,11781,CDM,270,RC,,HCPCS,outpatient,,,$102.51 ,$35.88 ,,$54.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.88 ,75,,,percent of total billed charges,75% of total billed charges,$76.88 ,75,,,percent of total billed charges,75% of total billed charges,$76.88 ,75,,,percent of total billed charges,75% of total billed charges,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.01 ,80,,,percent of total billed charges,80% of total billed charges,$32.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.88 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.76 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$92.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.99 ,$97.38 ,
DERMABOND PEN,11953,CDM,270,RC,,HCPCS,outpatient,,,$290.37 ,$101.63 ,,$155.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$155.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$217.78 ,75,,,percent of total billed charges,75% of total billed charges,$217.78 ,75,,,percent of total billed charges,75% of total billed charges,$217.78 ,75,,,percent of total billed charges,75% of total billed charges,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$232.30 ,80,,,percent of total billed charges,80% of total billed charges,$91.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$203.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$223.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$90.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$261.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$275.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$217.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$217.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.62 ,$275.85 ,
DERMAL CURETTE STERILE DISP 3MM,30017,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DERMAL CURETTE STERILE DISP 5MM,CDM,CDM,270,RC,,HCPCS,outpatient,,,$11.13 ,$3.90 ,,$5.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.35 ,75,,,percent of total billed charges,75% of total billed charges,$8.35 ,75,,,percent of total billed charges,75% of total billed charges,$8.35 ,75,,,percent of total billed charges,75% of total billed charges,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.90 ,80,,,percent of total billed charges,80% of total billed charges,$3.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.17 ,$10.57 ,
DERMAL CURETTE STERILE DISP 4MM,CDM,CDM,270,RC,,HCPCS,outpatient,,,$11.35 ,$3.97 ,,$6.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.51 ,75,,,percent of total billed charges,75% of total billed charges,$8.51 ,75,,,percent of total billed charges,75% of total billed charges,$8.51 ,75,,,percent of total billed charges,75% of total billed charges,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.08 ,80,,,percent of total billed charges,80% of total billed charges,$3.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.21 ,$10.78 ,
DERMAPLAST,11240,CDM,270,RC,,HCPCS,outpatient,,,$17.11 ,$5.99 ,,$9.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.83 ,75,,,percent of total billed charges,75% of total billed charges,$12.83 ,75,,,percent of total billed charges,75% of total billed charges,$12.83 ,75,,,percent of total billed charges,75% of total billed charges,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.69 ,80,,,percent of total billed charges,80% of total billed charges,$5.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.34 ,$16.25 ,
DIAPER ADULT XL,12306,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DISPOSABLE CORE BIOPSY INST. 22 MM,28705,CDM,270,RC,,HCPCS,outpatient,,,$210.00 ,$73.50 ,,$112.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$157.50 ,75,,,percent of total billed charges,75% of total billed charges,$157.50 ,75,,,percent of total billed charges,75% of total billed charges,$157.50 ,75,,,percent of total billed charges,75% of total billed charges,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.00 ,80,,,percent of total billed charges,80% of total billed charges,$66.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$73.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$147.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$189.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$199.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$157.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$157.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$157.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.95 ,$199.50 ,
DISPOSABLE INJECTOR NM,12788,CDM,270,RC,,HCPCS,outpatient,,,$140.13 ,$49.05 ,,$75.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.10 ,75,,,percent of total billed charges,75% of total billed charges,$105.10 ,75,,,percent of total billed charges,75% of total billed charges,$105.10 ,75,,,percent of total billed charges,75% of total billed charges,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.10 ,80,,,percent of total billed charges,80% of total billed charges,$44.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.33 ,$133.12 ,
DISPOSABLE LMA AIRWAY #6 ADULT,12642,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
DISPOSABLE LMA AIRWAY #1 NEONATE,12643,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
DISPOSABLE LMA AIRWAY #1.5 INFANT,12644,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
DISPOSABLE LMA AIRWAY #2 INFANT/CHILD,12645,CDM,270,RC,,HCPCS,outpatient,,,$57.23 ,$20.03 ,,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$42.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges,$18.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,$54.37 ,
DISPOSABLE SUCTION VALVE,12198,CDM,270,RC,,HCPCS,outpatient,,,$58.89 ,$20.61 ,,$31.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.17 ,75,,,percent of total billed charges,75% of total billed charges,$44.17 ,75,,,percent of total billed charges,75% of total billed charges,$44.17 ,75,,,percent of total billed charges,75% of total billed charges,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.11 ,80,,,percent of total billed charges,80% of total billed charges,$18.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.48 ,$55.95 ,
DRAIN BAG URETERAL 400CC,11302,CDM,272,RC,,HCPCS,outpatient,,,$115.77 ,$40.52 ,,$62.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.83 ,75,,,percent of total billed charges,75% of total billed charges,$86.83 ,75,,,percent of total billed charges,75% of total billed charges,$86.83 ,75,,,percent of total billed charges,75% of total billed charges,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.62 ,80,,,percent of total billed charges,80% of total billed charges,$36.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$89.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$104.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$109.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$86.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.58 ,$109.98 ,
DRAIN CATH BONANNO,28571,CDM,270,RC,,HCPCS,outpatient,,,$473.44 ,$165.70 ,,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.08 ,75,,,percent of total billed charges,75% of total billed charges,$355.08 ,75,,,percent of total billed charges,75% of total billed charges,$355.08 ,75,,,percent of total billed charges,75% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.75 ,80,,,percent of total billed charges,80% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$165.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$148.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$426.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$449.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$440.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$355.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$355.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$355.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.32 ,$449.77 ,
DRAIN W/ TROCAR 1/8,11612,CDM,270,RC,,HCPCS,outpatient,,,$48.79 ,$17.08 ,,$26.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.03 ,80,,,percent of total billed charges,80% of total billed charges,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.51 ,$46.35 ,
DRAWTEX HYDROCONDUCTIVE DRESSING 4X4,30083,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
DRAWTEX HYDROCONDUCTIVE DRESSING 4X39,30084,CDM,270,RC,,HCPCS,outpatient,,,$145.82 ,$51.04 ,,$78.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$109.37 ,75,,,percent of total billed charges,75% of total billed charges,$109.37 ,75,,,percent of total billed charges,75% of total billed charges,$109.37 ,75,,,percent of total billed charges,75% of total billed charges,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.66 ,80,,,percent of total billed charges,80% of total billed charges,$46.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$51.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$102.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$45.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$131.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$109.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.43 ,$138.53 ,
DRESSING 6 X 8 TEGADERM,11006,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DRESSING ADAPTIC 3 X 8  2015,30129,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DRESSING ADAPTIC STERILE 3 X 8 (DO NOT USE),93095,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
DRESSING BARRIER ACTICOAT FLEX 3 4X4,30016,CDM,270,RC,,HCPCS,outpatient,,,$31.22 ,$10.93 ,,$16.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.42 ,75,,,percent of total billed charges,75% of total billed charges,$23.42 ,75,,,percent of total billed charges,75% of total billed charges,$23.42 ,75,,,percent of total billed charges,75% of total billed charges,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.98 ,80,,,percent of total billed charges,80% of total billed charges,$9.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.09 ,$29.66 ,
DRESSING TEGADERM SURESITE 2.4 X 2.8  MSC2703,12826,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Dental Suture 100-6120,28668,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Dermablade Biopsy Blades,30047,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Digni. Stool Management,30166,CDM,270,RC,,HCPCS,outpatient,,,$64.26 ,$22.49 ,,$34.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.20 ,75,,,percent of total billed charges,75% of total billed charges,$48.20 ,75,,,percent of total billed charges,75% of total billed charges,$48.20 ,75,,,percent of total billed charges,75% of total billed charges,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,80,,,percent of total billed charges,80% of total billed charges,$20.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$57.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.53 ,$61.05 ,
Disp Laryn. Blade MC #3,30218,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Disp. Laryn. Blade Miller #3,30219,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Disp. Laryn. Blade MAC #3,30220,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Disp. Laryn. Blade MC #4,30221,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Disp. Laryn. Blade Miller #4,30222,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Disp. Laryn. Handle,30223,CDM,270,RC,,HCPCS,outpatient,,,$21.66 ,$7.58 ,,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$16.25 ,75,,,percent of total billed charges,75% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges,$6.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.22 ,$20.58 ,
Dressing Optifoam Basic 4x5,30098,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Dressing Optifoam Basic 3x3,20385,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Dressing Rope Prisma Matrix,203207,CDM,270,RC,,HCPCS,outpatient,,,$143.55 ,$50.24 ,,$76.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$107.66 ,75,,,percent of total billed charges,75% of total billed charges,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.84 ,80,,,percent of total billed charges,80% of total billed charges,$45.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$107.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.99 ,$136.37 ,
E Z WRAP CANNULA EAR WRAP,12407,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
E.Z. SET SHORT 23 X 3/4,12250,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
E.Z. SET SHORT 25 X 3/4,12251,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
EAR WICK,16023,CDM,270,RC,,HCPCS,outpatient,,,$20.76 ,$7.27 ,,$11.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.57 ,75,,,percent of total billed charges,75% of total billed charges,$15.57 ,75,,,percent of total billed charges,75% of total billed charges,$15.57 ,75,,,percent of total billed charges,75% of total billed charges,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.61 ,80,,,percent of total billed charges,80% of total billed charges,$6.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.05 ,$19.72 ,
EASY CAP CO2 DETECTOR,11736,CDM,270,RC,,HCPCS,outpatient,,,$41.13 ,$14.40 ,,$22.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.85 ,75,,,percent of total billed charges,75% of total billed charges,$30.85 ,75,,,percent of total billed charges,75% of total billed charges,$30.85 ,75,,,percent of total billed charges,75% of total billed charges,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.90 ,80,,,percent of total billed charges,80% of total billed charges,$13.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.02 ,$39.07 ,
EDUCARE PAPER WOUND RULER,30025,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
"ELASTOPLAST 3""",11345,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ELBOW CRITICAL CARE VENT,12619,CDM,270,RC,,HCPCS,outpatient,,,$31.24 ,$10.93 ,,$16.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.43 ,75,,,percent of total billed charges,75% of total billed charges,$23.43 ,75,,,percent of total billed charges,75% of total billed charges,$23.43 ,75,,,percent of total billed charges,75% of total billed charges,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.99 ,80,,,percent of total billed charges,80% of total billed charges,$9.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.09 ,$29.68 ,
ELECTRODE ADULT 5 pk,11790,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ELECTRODE EXTENDED BLADE,11429,CDM,270,RC,,HCPCS,outpatient,,,$21.97 ,$7.69 ,,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.48 ,75,,,percent of total billed charges,75% of total billed charges,$16.48 ,75,,,percent of total billed charges,75% of total billed charges,$16.48 ,75,,,percent of total billed charges,75% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.69 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.28 ,$20.87 ,
ELECTRODE NEEDLE TIP MEGADYNE,12616,CDM,270,RC,,HCPCS,outpatient,,,$47.12 ,$16.49 ,,$25.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.34 ,75,,,percent of total billed charges,75% of total billed charges,$35.34 ,75,,,percent of total billed charges,75% of total billed charges,$35.34 ,75,,,percent of total billed charges,75% of total billed charges,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.70 ,80,,,percent of total billed charges,80% of total billed charges,$14.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.19 ,$44.76 ,
ELECTRODE NEONATAL/PEDIATRIC,11789,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ELECTRODE PAD LARGE W/CORD,12809,CDM,270,RC,,HCPCS,outpatient,,,$26.22 ,$9.18 ,,$14.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.67 ,75,,,percent of total billed charges,75% of total billed charges,$19.67 ,75,,,percent of total billed charges,75% of total billed charges,$19.67 ,75,,,percent of total billed charges,75% of total billed charges,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.98 ,80,,,percent of total billed charges,80% of total billed charges,$8.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.11 ,$24.91 ,
ELECTRODE PADS FOR 25-80 LBS,12659,CDM,270,RC,,HCPCS,outpatient,,,$24.57 ,$8.60 ,,$13.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.43 ,75,,,percent of total billed charges,75% of total billed charges,$18.43 ,75,,,percent of total billed charges,75% of total billed charges,$18.43 ,75,,,percent of total billed charges,75% of total billed charges,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,80,,,percent of total billed charges,80% of total billed charges,$7.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.11 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.79 ,$23.34 ,
ELECTRODE ZOLL ONE STEP PEDIATRIC,12558,CDM,270,RC,,HCPCS,outpatient,,,$243.65 ,$85.28 ,,$130.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$182.74 ,75,,,percent of total billed charges,75% of total billed charges,$182.74 ,75,,,percent of total billed charges,75% of total billed charges,$182.74 ,75,,,percent of total billed charges,75% of total billed charges,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.92 ,80,,,percent of total billed charges,80% of total billed charges,$77.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$85.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$187.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$75.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$219.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$231.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$182.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$182.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$207.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.51 ,$231.47 ,
ELECTRODE ZOLL ONE STEP COMPLETE,12559,CDM,270,RC,,HCPCS,outpatient,,,$260.10 ,$91.04 ,,$139.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$195.08 ,75,,,percent of total billed charges,75% of total billed charges,$195.08 ,75,,,percent of total billed charges,75% of total billed charges,$195.08 ,75,,,percent of total billed charges,75% of total billed charges,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.08 ,80,,,percent of total billed charges,80% of total billed charges,$82.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$91.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$208.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$200.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$80.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$234.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$247.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$195.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$195.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$221.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.72 ,$247.10 ,
ELONGATED AEROSOL MASK,11630,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO BABCOCK 10MM CLAMP,11655,CDM,270,RC,,HCPCS,outpatient,,,$324.25 ,$113.49 ,,$173.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$243.19 ,75,,,percent of total billed charges,75% of total billed charges,$243.19 ,75,,,percent of total billed charges,75% of total billed charges,$243.19 ,75,,,percent of total billed charges,75% of total billed charges,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$259.40 ,80,,,percent of total billed charges,80% of total billed charges,$102.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$113.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$226.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$226.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$249.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$101.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$101.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$100.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$291.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$308.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$243.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$243.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$275.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.23 ,$308.04 ,
ENDO CLIP APPLIER 5MM,12542,CDM,270,RC,,HCPCS,outpatient,,,$270.27 ,$94.59 ,,$144.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$144.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$202.70 ,75,,,percent of total billed charges,75% of total billed charges,$202.70 ,75,,,percent of total billed charges,75% of total billed charges,$202.70 ,75,,,percent of total billed charges,75% of total billed charges,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$216.22 ,80,,,percent of total billed charges,80% of total billed charges,$85.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$94.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$216.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$208.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$83.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$243.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$256.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$251.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$202.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$229.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.70 ,$256.76 ,
ENDO CLIP L,12624,CDM,270,RC,,HCPCS,outpatient,,,$416.97 ,$145.94 ,,$223.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$223.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$312.73 ,75,,,percent of total billed charges,75% of total billed charges,$312.73 ,75,,,percent of total billed charges,75% of total billed charges,$312.73 ,75,,,percent of total billed charges,75% of total billed charges,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.58 ,80,,,percent of total billed charges,80% of total billed charges,$131.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$145.94 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$333.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$291.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$321.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$129.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$375.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$396.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$333.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$387.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$312.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$354.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.31 ,$396.12 ,
ENDO LINEAR CUTTER ARTICULATING,12706,CDM,270,RC,,HCPCS,outpatient,,,"$1,663.96 ",$582.39 ,,$891.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$891.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,331.17 ",80,,,percent of total billed charges,80% of total billed charges,$526.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$582.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,331.17 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,164.77 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,164.77 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,281.25 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$520.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$324.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$515.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,497.56 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$334.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,580.76 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,331.17 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$330.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,547.48 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,247.97 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$334.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,414.37 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$330.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$324.47 ,"$1,580.76 ",
ENDO LINEAR CUTTER 45MM  ATS45,12540,CDM,270,RC,,HCPCS,outpatient,,,$960.28 ,$336.10 ,,$514.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$514.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$720.21 ,75,,,percent of total billed charges,75% of total billed charges,$720.21 ,75,,,percent of total billed charges,75% of total billed charges,$720.21 ,75,,,percent of total billed charges,75% of total billed charges,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$768.22 ,80,,,percent of total billed charges,80% of total billed charges,$303.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$336.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$768.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$672.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$672.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$739.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$300.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$297.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$864.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$192.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$912.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$768.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$893.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$720.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$720.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$720.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$816.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.25 ,$912.27 ,
ENDO PEANUT 5MMDEVICE,11738,CDM,270,RC,,HCPCS,outpatient,,,$293.50 ,$102.73 ,,$157.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$157.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$220.13 ,75,,,percent of total billed charges,75% of total billed charges,$220.13 ,75,,,percent of total billed charges,75% of total billed charges,$220.13 ,75,,,percent of total billed charges,75% of total billed charges,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$234.80 ,80,,,percent of total billed charges,80% of total billed charges,$92.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$102.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$234.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$205.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$226.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$91.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$90.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$264.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$278.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$220.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$220.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$220.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$249.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.23 ,$278.83 ,
ENDO RETRACT 10MM,11744,CDM,270,RC,,HCPCS,outpatient,,,$85.35 ,$29.87 ,,$45.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.01 ,75,,,percent of total billed charges,75% of total billed charges,$64.01 ,75,,,percent of total billed charges,75% of total billed charges,$64.01 ,75,,,percent of total billed charges,75% of total billed charges,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.28 ,80,,,percent of total billed charges,80% of total billed charges,$26.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$59.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$76.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.64 ,$81.08 ,
ENDO ROTATING MULTI CLIP ER320,12560,CDM,270,RC,,HCPCS,outpatient,,,$154.44 ,$54.05 ,,$82.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.83 ,75,,,percent of total billed charges,75% of total billed charges,$115.83 ,75,,,percent of total billed charges,75% of total billed charges,$115.83 ,75,,,percent of total billed charges,75% of total billed charges,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$123.55 ,80,,,percent of total billed charges,80% of total billed charges,$48.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$47.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$139.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$146.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$115.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$115.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.12 ,$146.72 ,
ENDO ROTATING MULTI CLIP ER420,12549,CDM,270,RC,,HCPCS,outpatient,,,$417.19 ,$146.02 ,,$223.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$223.61 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$312.89 ,75,,,percent of total billed charges,75% of total billed charges,$312.89 ,75,,,percent of total billed charges,75% of total billed charges,$312.89 ,75,,,percent of total billed charges,75% of total billed charges,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$333.75 ,80,,,percent of total billed charges,80% of total billed charges,$131.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$146.02 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$333.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$292.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$321.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$129.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$375.47 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$396.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$333.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$387.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$312.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$354.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.35 ,$396.33 ,
ENDO SHEARS 5MM W/UNIPOLAR CAUTERY,11749,CDM,270,RC,,HCPCS,outpatient,,,$78.83 ,$27.59 ,,$42.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.12 ,75,,,percent of total billed charges,75% of total billed charges,$59.12 ,75,,,percent of total billed charges,75% of total billed charges,$59.12 ,75,,,percent of total billed charges,75% of total billed charges,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.06 ,80,,,percent of total billed charges,80% of total billed charges,$24.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$27.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$70.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$59.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.37 ,$74.89 ,
ENDO TUBE 2.5,12111,CDM,270,RC,,HCPCS,outpatient,,,$126.48 ,$44.27 ,,$67.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.18 ,80,,,percent of total billed charges,80% of total billed charges,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$113.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$120.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.66 ,$120.16 ,
ENDO TUBE 3.0,12113,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 3.5,12112,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 4.0,12114,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 4.5,12115,CDM,270,RC,,HCPCS,outpatient,,,$10.03 ,$3.51 ,,$5.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.52 ,75,,,percent of total billed charges,75% of total billed charges,$7.52 ,75,,,percent of total billed charges,75% of total billed charges,$7.52 ,75,,,percent of total billed charges,75% of total billed charges,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.02 ,80,,,percent of total billed charges,80% of total billed charges,$3.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.96 ,$9.53 ,
ENDO TUBE 5.0,12116,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 5.5,12117,CDM,270,RC,,HCPCS,outpatient,,,$126.48 ,$44.27 ,,$67.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$94.86 ,75,,,percent of total billed charges,75% of total billed charges,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.18 ,80,,,percent of total billed charges,80% of total billed charges,$39.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$113.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$120.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.66 ,$120.16 ,
ENDO TUBE 6.0,12118,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 6.5,12119,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 7.0,12120,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 7.5,12121,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 8.0,12122,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 8.5,12123,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 9.0,12124,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDO TUBE 9.5,12125,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ENDOLOOP COATED VICRYL,12593,CDM,270,RC,,HCPCS,outpatient,,,$93.04 ,$32.56 ,,$49.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.78 ,75,,,percent of total billed charges,75% of total billed charges,$69.78 ,75,,,percent of total billed charges,75% of total billed charges,$69.78 ,75,,,percent of total billed charges,75% of total billed charges,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.43 ,80,,,percent of total billed charges,80% of total billed charges,$29.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.14 ,$88.39 ,
ENDOPOUCH 10MM SPEC BAG,11651,CDM,270,RC,,HCPCS,outpatient,,,$246.25 ,$86.19 ,,$131.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$184.69 ,75,,,percent of total billed charges,75% of total billed charges,$184.69 ,75,,,percent of total billed charges,75% of total billed charges,$184.69 ,75,,,percent of total billed charges,75% of total billed charges,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.00 ,80,,,percent of total billed charges,80% of total billed charges,$77.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$221.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$233.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$184.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$184.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$184.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.02 ,$233.94 ,
ENDOTRACHEAL TUBE HOLDER,11970,CDM,270,RC,,HCPCS,outpatient,,,$35.79 ,$12.53 ,,$19.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.84 ,75,,,percent of total billed charges,75% of total billed charges,$26.84 ,75,,,percent of total billed charges,75% of total billed charges,$26.84 ,75,,,percent of total billed charges,75% of total billed charges,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.63 ,80,,,percent of total billed charges,80% of total billed charges,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.98 ,$34.00 ,
EPIDURAL TRAY,11653,CDM,270,RC,,HCPCS,outpatient,,,$186.58 ,$65.30 ,,$100.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.94 ,75,,,percent of total billed charges,75% of total billed charges,$139.94 ,75,,,percent of total billed charges,75% of total billed charges,$139.94 ,75,,,percent of total billed charges,75% of total billed charges,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.26 ,80,,,percent of total billed charges,80% of total billed charges,$59.00 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$143.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$167.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$177.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.38 ,$177.25 ,
EPIFIX 2 X 2 SHEET,20390,CDM,636,RC,Q4186,HCPCS,both,,,"$3,401.00 ","$1,190.35 ",,"$1,822.94 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,822.94 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,720.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,075.40 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,190.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,720.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,380.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,380.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,618.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$676.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,064.85 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$663.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,054.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,060.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$682.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,230.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,720.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$676.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,162.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,550.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$682.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,890.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$676.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$663.20 ,"$3,230.95 ",
EPIFIX 3 X 5 GS-5350,93029,CDM,636,RC,Q4186,HCPCS,both,,,"$6,867.00 ","$2,403.45 ",,"$3,680.71 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,680.71 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,493.60 ",80,,,percent of total billed charges,80% of total billed charges,"$2,171.35 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,403.45 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,493.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,806.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,806.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,287.59 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,365.85 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,150.06 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,339.07 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,128.77 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$6,180.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,378.89 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,523.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,493.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,365.85 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,386.31 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,150.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,378.89 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,836.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,365.85 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,339.07 ","$6,523.65 ",
EPIFIX 4 X 4,93028,CDM,636,RC,Q4186,HCPCS,both,,,"$10,675.56 ","$3,736.45 ",,"$5,722.10 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,722.10 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$8,540.45 ",80,,,percent of total billed charges,80% of total billed charges,"$3,375.61 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,736.45 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,342.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,540.45 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,472.89 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,472.89 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,220.18 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,342.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,123.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,342.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,342.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,342.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,342.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,081.73 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,309.42 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$9,608.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,143.65 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$10,141.78 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,540.45 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,123.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,928.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,006.67 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,143.65 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,074.23 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,123.37 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,081.73 ","$10,141.78 ",
EPISTASIS PACKING DRAWSTRING 10 CM,11818,CDM,272,RC,,HCPCS,outpatient,,,$138.82 ,$48.59 ,,$74.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$104.12 ,75,,,percent of total billed charges,75% of total billed charges,$104.12 ,75,,,percent of total billed charges,75% of total billed charges,$104.12 ,75,,,percent of total billed charges,75% of total billed charges,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.06 ,80,,,percent of total billed charges,80% of total billed charges,$43.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$104.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$104.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$118.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.07 ,$131.88 ,
ESMARK BANDAGE 3,11347,CDM,270,RC,,HCPCS,outpatient,,,$27.68 ,$9.69 ,,$14.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.76 ,75,,,percent of total billed charges,75% of total billed charges,$20.76 ,75,,,percent of total billed charges,75% of total billed charges,$20.76 ,75,,,percent of total billed charges,75% of total billed charges,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.14 ,80,,,percent of total billed charges,80% of total billed charges,$8.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.69 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.40 ,$26.30 ,
ESMARK BANDAGE 6,11348,CDM,270,RC,,HCPCS,outpatient,,,$52.85 ,$18.50 ,,$28.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.64 ,75,,,percent of total billed charges,75% of total billed charges,$39.64 ,75,,,percent of total billed charges,75% of total billed charges,$39.64 ,75,,,percent of total billed charges,75% of total billed charges,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.28 ,80,,,percent of total billed charges,80% of total billed charges,$16.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$47.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.31 ,$50.21 ,
ET TUBE 4.5,28657,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SHARN,28658,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 3,28654,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ET TUBE SZ 3.5,28655,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 4,28656,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 5.5,28659,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 6,28660,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 6.5,28661,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
ET TUBE SZ 7,28662,CDM,272,RC,,HCPCS,outpatient,,,$23.63 ,$8.27 ,,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$17.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges,$7.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.61 ,$22.45 ,
EVACUATED CONTAINER 1000ml,11866,CDM,270,RC,,HCPCS,outpatient,,,$58.75 ,$20.56 ,,$31.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.06 ,75,,,percent of total billed charges,75% of total billed charges,$44.06 ,75,,,percent of total billed charges,75% of total billed charges,$44.06 ,75,,,percent of total billed charges,75% of total billed charges,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.00 ,80,,,percent of total billed charges,80% of total billed charges,$18.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.46 ,$55.81 ,
EXT. SET 36 W / FILTER,11813,CDM,270,RC,,HCPCS,outpatient,,,$18.55 ,$6.49 ,,$9.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.91 ,75,,,percent of total billed charges,75% of total billed charges,$13.91 ,75,,,percent of total billed charges,75% of total billed charges,$13.91 ,75,,,percent of total billed charges,75% of total billed charges,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.84 ,80,,,percent of total billed charges,80% of total billed charges,$5.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.62 ,$17.62 ,
EXTRICATION COLLAR PEDIATRIC,90393,CDM,270,RC,,HCPCS,outpatient,,,$52.00 ,$18.20 ,,$27.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$39.00 ,75,,,percent of total billed charges,75% of total billed charges,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.60 ,80,,,percent of total billed charges,80% of total billed charges,$16.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.14 ,$49.40 ,
EXTRICATION COLLAR NO NECK,90392,CDM,270,RC,,HCPCS,outpatient,,,$42.26 ,$14.79 ,,$22.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.70 ,75,,,percent of total billed charges,75% of total billed charges,$31.70 ,75,,,percent of total billed charges,75% of total billed charges,$31.70 ,75,,,percent of total billed charges,75% of total billed charges,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.81 ,80,,,percent of total billed charges,80% of total billed charges,$13.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.24 ,$40.15 ,
EXTRICATION COLLAR ADULT,90391,CDM,270,RC,,HCPCS,outpatient,,,$54.00 ,$18.90 ,,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$40.50 ,75,,,percent of total billed charges,75% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges,$17.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,$51.30 ,
EXUDERM SATIN HYDROCOLLOID DRESSING 4X4,30086,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
EXUDERM SATIN HYDROCOLLOID DRESSING 6X6,30087,CDM,270,RC,,HCPCS,outpatient,,,$13.70 ,$4.80 ,,$7.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.28 ,75,,,percent of total billed charges,75% of total billed charges,$10.28 ,75,,,percent of total billed charges,75% of total billed charges,$10.28 ,75,,,percent of total billed charges,75% of total billed charges,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.96 ,80,,,percent of total billed charges,80% of total billed charges,$4.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.28 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.67 ,$13.02 ,
EYE GUARDS,90471,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
EZ-IO NEEDLE 15MM,12678,CDM,270,RC,,HCPCS,outpatient,,,$546.40 ,$191.24 ,,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$191.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$420.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$169.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$491.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$519.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.55 ,$519.08 ,
EZ-IO NEEDLE 25MM,12679,CDM,270,RC,,HCPCS,outpatient,,,$546.40 ,$191.24 ,,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$191.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$420.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$169.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$491.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$519.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.55 ,$519.08 ,
EZ-IO NEEDLE 45MM,12680,CDM,270,RC,,HCPCS,outpatient,,,$546.40 ,$191.24 ,,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$191.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$420.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$169.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$491.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$519.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.55 ,$519.08 ,
Eakin Cohesive Paste,30123,CDM,270,RC,,HCPCS,outpatient,,,$34.96 ,$12.24 ,,$18.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.22 ,75,,,percent of total billed charges,75% of total billed charges,$26.22 ,75,,,percent of total billed charges,75% of total billed charges,$26.22 ,75,,,percent of total billed charges,75% of total billed charges,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.97 ,80,,,percent of total billed charges,80% of total billed charges,$11.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.82 ,$33.21 ,
"Eakin cohesive 2"" barrier",30124,CDM,270,RC,,HCPCS,outpatient,,,$16.69 ,$5.84 ,,$8.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.52 ,75,,,percent of total billed charges,75% of total billed charges,$12.52 ,75,,,percent of total billed charges,75% of total billed charges,$12.52 ,75,,,percent of total billed charges,75% of total billed charges,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.35 ,80,,,percent of total billed charges,80% of total billed charges,$5.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.25 ,$15.86 ,
Epicord 2X3,30113,CDM,636,RC,Q4187,HCPCS,both,,,"$3,196.94 ","$1,118.93 ",,"$1,713.56 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,713.56 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,557.55 ",80,,,percent of total billed charges,80% of total billed charges,"$1,010.87 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,118.93 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,557.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,237.86 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,237.86 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,461.64 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,000.96 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$623.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$991.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,877.25 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$641.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,037.09 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,557.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$635.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,973.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,397.71 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$641.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,717.40 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$635.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$623.40 ,"$3,037.09 ",
Epicord 3x5,20321,CDM,636,RC,Q4187,HCPCS,both,,,"$11,506.12 ","$4,027.14 ",,"$6,167.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,167.28 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$9,204.90 ",80,,,percent of total billed charges,80% of total billed charges,"$3,638.24 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$4,027.14 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,204.90 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,054.28 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,054.28 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,859.71 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,288.57 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,602.57 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,243.69 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,566.90 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$10,355.51 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,310.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$10,930.81 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,204.90 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,288.57 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$10,700.69 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,629.59 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,310.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,780.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,288.57 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,243.69 ","$10,930.81 ",
Epifix 18mm Disk,30198,CDM,636,RC,Q4186,HCPCS,both,,,"$2,301.94 ",$805.68 ,,"$1,233.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,233.84 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,841.55 ",80,,,percent of total billed charges,80% of total billed charges,$727.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$805.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,841.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,611.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,611.36 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,772.49 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$457.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$720.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$448.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$713.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,071.75 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$462.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,186.84 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,841.55 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$457.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,140.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,726.46 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$462.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,956.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$457.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$448.88 ,"$2,186.84 ",
Epifix 2X4 SHEET,20313,CDM,636,RC,Q4186,HCPCS,both,,,"$4,739.92 ","$1,658.97 ",,"$2,540.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,540.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,658.97 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,317.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,317.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,649.74 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,469.38 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,265.93 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$951.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,502.92 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,408.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$951.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$924.28 ,"$4,502.92 ",
Epifix 2x3 Sheet,20347,CDM,278,RC,Q4186,HCPCS,both,,,"$4,739.92 ","$1,658.97 ",,"$2,540.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,540.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges,"$1,498.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,658.97 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,317.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,317.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,649.74 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,484.07 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,469.38 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,265.93 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$951.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,502.92 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,791.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,408.13 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,554.94 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$951.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,028.93 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$942.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$924.28 ,"$4,502.92 ",
Epifix 2x3 mesh,28835,CDM,636,RC,Q4186,HCPCS,both,,,"$3,938.00 ","$1,378.30 ",,"$2,110.77 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,110.77 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,150.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,245.20 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,378.30 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,150.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,756.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,756.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,032.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,232.99 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$767.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,220.78 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,544.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$790.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,741.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,150.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$783.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,662.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,953.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$790.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,347.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$783.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$767.91 ,"$3,741.10 ",
Epifix 3x4 Sheet,20341,CDM,278,RC,Q4186,HCPCS,both,,,"$8,441.64 ","$2,954.57 ",,"$4,524.72 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,524.72 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,753.31 ",80,,,percent of total billed charges,80% of total billed charges,"$2,669.25 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,954.57 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,753.31 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,909.15 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,909.15 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,500.06 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,679.04 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,643.08 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,646.12 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,616.91 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$7,597.48 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,695.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,019.56 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,753.31 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,679.04 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,850.73 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,331.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,695.08 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,175.39 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,679.04 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,646.12 ","$8,019.56 ",
Epifix 4x4.5,30184,CDM,636,RC,Q4186,HCPCS,both,,,"$3,882.00 ","$1,358.70 ",,"$2,080.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,080.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,105.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,227.49 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,358.70 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,105.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,717.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,717.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,989.14 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,215.45 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$756.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,203.42 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,493.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$779.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,687.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,105.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$772.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,610.26 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,911.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$779.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,299.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$772.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$756.99 ,"$3,687.90 ",
Epifix 5x6 Sheet,20348,CDM,636,RC,Q4186,HCPCS,both,,,"$20,262.80 ","$7,091.98 ",,"$10,860.86 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$10,860.86 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$16,210.24 ",80,,,percent of total billed charges,80% of total billed charges,"$6,407.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$7,091.98 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$16,210.24 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$14,183.96 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$14,183.96 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$15,602.36 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,030.27 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,344.28 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,951.25 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$6,281.47 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$18,236.52 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$4,068.77 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$19,249.66 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$16,210.24 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,030.27 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$18,844.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$15,197.10 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,068.77 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$17,223.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,030.27 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,951.25 ","$19,249.66 ",
Epifix 7x7,20263,CDM,636,RC,Q4186,HCPCS,both,,,"$33,906.18 ","$11,867.16 ",,"$18,173.71 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$18,173.71 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$27,124.94 ",80,,,percent of total billed charges,80% of total billed charges,"$10,721.13 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$11,867.16 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$10,616.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$27,124.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$23,734.33 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$23,734.33 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$26,107.76 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$10,616.03 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,743.94 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$10,616.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$10,616.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$10,616.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$10,616.02 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,611.71 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$10,510.92 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$30,515.56 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$6,808.36 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$32,210.87 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$27,124.94 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$6,743.94 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$31,532.75 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$25,429.64 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,808.36 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$28,820.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,743.94 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$6,611.71 ","$32,210.87 ",
Epifix mesh 3.5x3.5,30159,CDM,636,RC,Q4186,HCPCS,both,,,"$3,582.00 ","$1,253.70 ",,"$1,919.95 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,919.95 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,865.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,132.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,253.70 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,865.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,507.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,507.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,758.14 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$712.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,121.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,110.42 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,223.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$719.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,402.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,865.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$712.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,331.26 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,686.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$719.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,044.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$712.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$698.49 ,"$3,402.90 ",
"Extension set 20"" MRI",11405,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE MASK ADULT SZ 5 KING,12583,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE MASK ADULT SZ 6 KING,12605,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE MASK CHILD SZ 4 KING,12582,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE MASK INFANT SZ 2 KING,12580,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE MASK TODDLER SZ 3 KING,12581,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FACE TENT 15MM CON KING,12579,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FEEDING CONT. KANGAROO,12487,CDM,270,RC,,HCPCS,outpatient,,,$26.59 ,$9.31 ,,$14.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.94 ,75,,,percent of total billed charges,75% of total billed charges,$19.94 ,75,,,percent of total billed charges,75% of total billed charges,$19.94 ,75,,,percent of total billed charges,75% of total billed charges,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.27 ,80,,,percent of total billed charges,80% of total billed charges,$8.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.61 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.19 ,$25.26 ,
FEEDING TUBE ENTRIFLEX,11881,CDM,270,RC,,HCPCS,outpatient,,,$42.13 ,$14.75 ,,$22.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.60 ,75,,,percent of total billed charges,75% of total billed charges,$31.60 ,75,,,percent of total billed charges,75% of total billed charges,$31.60 ,75,,,percent of total billed charges,75% of total billed charges,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.70 ,80,,,percent of total billed charges,80% of total billed charges,$13.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.22 ,$40.02 ,
FEEDING TUBE W/ Y- PORT KANGAROO 20FR,28892,CDM,270,RC,,HCPCS,outpatient,,,$136.24 ,$47.68 ,,$73.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$73.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$102.18 ,75,,,percent of total billed charges,75% of total billed charges,$102.18 ,75,,,percent of total billed charges,75% of total billed charges,$102.18 ,75,,,percent of total billed charges,75% of total billed charges,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.99 ,80,,,percent of total billed charges,80% of total billed charges,$43.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$47.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$95.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$42.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$122.62 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$129.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$102.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.57 ,$129.43 ,
FEMALE CATH KIT,11407,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FIBRACOL PLUS DRESSING 2X2,30078,CDM,270,RC,,HCPCS,outpatient,,,$13.10 ,$4.59 ,,$7.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.83 ,75,,,percent of total billed charges,75% of total billed charges,$9.83 ,75,,,percent of total billed charges,75% of total billed charges,$9.83 ,75,,,percent of total billed charges,75% of total billed charges,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.48 ,80,,,percent of total billed charges,80% of total billed charges,$4.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.55 ,$12.45 ,
FIBRACOL PLUS DRESSING 4X4.375,30079,CDM,270,RC,,HCPCS,outpatient,,,$21.25 ,$7.44 ,,$11.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.94 ,75,,,percent of total billed charges,75% of total billed charges,$15.94 ,75,,,percent of total billed charges,75% of total billed charges,$15.94 ,75,,,percent of total billed charges,75% of total billed charges,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.00 ,80,,,percent of total billed charges,80% of total billed charges,$6.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.13 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.14 ,$20.19 ,
FINGER SPLINT BASEBALL MED,11360,CDM,270,RC,,HCPCS,outpatient,,,$20.00 ,$7.00 ,,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$15.00 ,75,,,percent of total billed charges,75% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges,$6.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.90 ,$19.00 ,
FINGER SPLINT FROG LARGE,12801,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FINGER SPLINT FROG SMALL,12799,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FINGER SPLINT FROG MEDIUM,12800,CDM,270,RC,,HCPCS,outpatient,,,$10.91 ,$3.82 ,,$5.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.18 ,75,,,percent of total billed charges,75% of total billed charges,$8.18 ,75,,,percent of total billed charges,75% of total billed charges,$8.18 ,75,,,percent of total billed charges,75% of total billed charges,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.73 ,80,,,percent of total billed charges,80% of total billed charges,$3.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.13 ,$10.36 ,
"FINGER SPLINT STRIPS 3/4 X18""",90633,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
FLO SET W / FILTER AND ADAPTER,11969,CDM,270,RC,,HCPCS,outpatient,,,$34.59 ,$12.11 ,,$18.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.94 ,75,,,percent of total billed charges,75% of total billed charges,$25.94 ,75,,,percent of total billed charges,75% of total billed charges,$25.94 ,75,,,percent of total billed charges,75% of total billed charges,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.67 ,80,,,percent of total billed charges,80% of total billed charges,$10.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.67 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.13 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.67 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$25.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.75 ,$32.86 ,
FLOW SENSOR FSII,11554,CDM,270,RC,,HCPCS,outpatient,,,$21.48 ,$7.52 ,,$11.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.11 ,75,,,percent of total billed charges,75% of total billed charges,$16.11 ,75,,,percent of total billed charges,75% of total billed charges,$16.11 ,75,,,percent of total billed charges,75% of total billed charges,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.18 ,80,,,percent of total billed charges,80% of total billed charges,$6.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.19 ,$20.41 ,
FLOWTRON DVT. CALF GARMENT REGULAR,12754,CDM,270,RC,,HCPCS,outpatient,,,$70.08 ,$24.53 ,,$37.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$52.56 ,75,,,percent of total billed charges,75% of total billed charges,$52.56 ,75,,,percent of total billed charges,75% of total billed charges,$52.56 ,75,,,percent of total billed charges,75% of total billed charges,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.06 ,80,,,percent of total billed charges,80% of total billed charges,$22.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$66.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$52.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.67 ,$66.58 ,
FLOWTRON DVT. CALF GARMENT LARGE,11906,CDM,270,RC,,HCPCS,outpatient,,,$212.33 ,$74.32 ,,$113.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$159.25 ,75,,,percent of total billed charges,75% of total billed charges,$159.25 ,75,,,percent of total billed charges,75% of total billed charges,$159.25 ,75,,,percent of total billed charges,75% of total billed charges,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$169.86 ,80,,,percent of total billed charges,80% of total billed charges,$67.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$74.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$191.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$201.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$159.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$159.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$180.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.40 ,$201.71 ,
FLUSHING PUMP ADAPTER,28645,CDM,270,RC,,HCPCS,outpatient,,,$62.84 ,$21.99 ,,$33.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.13 ,75,,,percent of total billed charges,75% of total billed charges,$47.13 ,75,,,percent of total billed charges,75% of total billed charges,$47.13 ,75,,,percent of total billed charges,75% of total billed charges,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.27 ,80,,,percent of total billed charges,80% of total billed charges,$19.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.25 ,$59.70 ,
FLUSHING PUMP TUBING maj-1608,28644,CDM,270,RC,,HCPCS,outpatient,,,$90.42 ,$31.65 ,,$48.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.82 ,75,,,percent of total billed charges,75% of total billed charges,$67.82 ,75,,,percent of total billed charges,75% of total billed charges,$67.82 ,75,,,percent of total billed charges,75% of total billed charges,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.34 ,80,,,percent of total billed charges,80% of total billed charges,$28.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$81.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$85.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$67.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.63 ,$85.90 ,
FOAM COLLAR LARGE,11889,CDM,274,RC,,HCPCS,outpatient,,,$13.81 ,$4.83 ,,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.69 ,$13.12 ,
FOAM COLLAR MEDIUM,11037,CDM,274,RC,,HCPCS,outpatient,,,$13.81 ,$4.83 ,,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.69 ,$13.12 ,
FOAM COLLAR SMALL,12350,CDM,274,RC,,HCPCS,outpatient,,,$17.85 ,$6.25 ,,$9.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,80,,,percent of total billed charges,80% of total billed charges,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.48 ,$16.96 ,
FOCUS SCISSOR GRIP 9CM,12550,CDM,270,RC,,HCPCS,outpatient,,,"$1,716.10 ",$600.64 ,,$919.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$919.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,372.88 ",80,,,percent of total billed charges,80% of total billed charges,$542.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$600.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,372.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.27 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,201.27 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,321.40 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$341.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$537.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$531.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,544.49 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$344.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,630.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,372.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$341.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,595.97 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,287.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$344.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,458.69 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$341.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$334.64 ,"$1,630.30 ",
FOLEY CATH 10 FR 3 CC,12404,CDM,270,RC,,HCPCS,outpatient,,,$18.89 ,$6.61 ,,$10.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.11 ,80,,,percent of total billed charges,80% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.68 ,$17.95 ,
FOLEY CATH 12 FR 5 CC,12094,CDM,270,RC,,HCPCS,outpatient,,,$14.42 ,$5.05 ,,$7.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.54 ,80,,,percent of total billed charges,80% of total billed charges,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.81 ,$13.70 ,
FOLEY CATH 14 FR 5 CC,12095,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 16 FR 5 CC,12096,CDM,270,RC,,HCPCS,outpatient,,,$14.42 ,$5.05 ,,$7.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$10.82 ,75,,,percent of total billed charges,75% of total billed charges,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.54 ,80,,,percent of total billed charges,80% of total billed charges,$4.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.81 ,$13.70 ,
FOLEY CATH 18 FR 5 CC,12097,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 20 FR 5 CC,12098,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 22 FR 5 CC,12099,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 24 FR 5 CC,12101,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 26 FR 5 CC,12100,CDM,270,RC,,HCPCS,outpatient,,,$18.21 ,$6.37 ,,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$13.66 ,75,,,percent of total billed charges,75% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges,$5.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.55 ,$17.30 ,
FOLEY CATH 8 FR 3 CC,12093,CDM,270,RC,,HCPCS,outpatient,,,$18.89 ,$6.61 ,,$10.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$14.17 ,75,,,percent of total billed charges,75% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.11 ,80,,,percent of total billed charges,80% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.68 ,$17.95 ,
FOLEY CATH COUDE TIP 20 FR,28897,CDM,270,RC,,HCPCS,outpatient,,,$74.63 ,$26.12 ,,$40.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.97 ,75,,,percent of total billed charges,75% of total billed charges,$55.97 ,75,,,percent of total billed charges,75% of total billed charges,$55.97 ,75,,,percent of total billed charges,75% of total billed charges,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.70 ,80,,,percent of total billed charges,80% of total billed charges,$23.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.55 ,$70.90 ,
FOLEY CATH TRAY 14 FR,11983,CDM,270,RC,,HCPCS,outpatient,,,$66.75 ,$23.36 ,,$35.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$50.06 ,75,,,percent of total billed charges,75% of total billed charges,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.40 ,80,,,percent of total billed charges,80% of total billed charges,$21.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.02 ,$63.41 ,
FOLEY CATH TRAY 16 FR,11035,CDM,270,RC,,HCPCS,outpatient,,,$17.85 ,$6.25 ,,$9.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$13.39 ,75,,,percent of total billed charges,75% of total billed charges,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.28 ,80,,,percent of total billed charges,80% of total billed charges,$5.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.48 ,$16.96 ,
FOLEY CATH TRAY 18 FR,11984,CDM,270,RC,,HCPCS,outpatient,,,$24.96 ,$8.74 ,,$13.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.38 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.72 ,75,,,percent of total billed charges,75% of total billed charges,$18.72 ,75,,,percent of total billed charges,75% of total billed charges,$18.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,80,,,percent of total billed charges,80% of total billed charges,$7.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.87 ,$23.71 ,
FOREARM SPLINT INFANT LG,11119,CDM,270,RC,,HCPCS,outpatient,,,$36.00 ,$12.60 ,,$19.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.00 ,75,,,percent of total billed charges,75% of total billed charges,$27.00 ,75,,,percent of total billed charges,75% of total billed charges,$27.00 ,75,,,percent of total billed charges,75% of total billed charges,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.80 ,80,,,percent of total billed charges,80% of total billed charges,$11.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.02 ,$34.20 ,
FOREARM SPLINT INFANT RIGHT,12771,CDM,270,RC,,HCPCS,outpatient,,,$19.95 ,$6.98 ,,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.89 ,$18.95 ,
FOREARM SPLINT LARGE LEFT,12352,CDM,270,RC,,HCPCS,outpatient,,,$40.00 ,$14.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.80 ,$38.00 ,
FOREARM SPLINT LARGE RIGHT,12772,CDM,270,RC,,HCPCS,outpatient,,,$19.95 ,$6.98 ,,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.89 ,$18.95 ,
FOREARM SPLINT M,17062,CDM,270,RC,,HCPCS,outpatient,,,$497.56 ,$174.15 ,,$266.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$266.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$373.17 ,75,,,percent of total billed charges,75% of total billed charges,$373.17 ,75,,,percent of total billed charges,75% of total billed charges,$373.17 ,75,,,percent of total billed charges,75% of total billed charges,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$398.05 ,80,,,percent of total billed charges,80% of total billed charges,$157.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$174.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$155.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$398.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$348.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$383.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$155.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$155.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$155.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$154.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$447.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$99.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$472.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$398.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$373.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$373.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$373.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$422.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.02 ,$472.68 ,
FOREARM SPLINT MEDIUM LEFT,12353,CDM,270,RC,,HCPCS,outpatient,,,$18.53 ,$6.49 ,,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.61 ,$17.60 ,
FOREARM SPLINT MEDIUM RIGHT,12773,CDM,270,RC,,HCPCS,outpatient,,,$19.95 ,$6.98 ,,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$14.96 ,75,,,percent of total billed charges,75% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges,$6.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.89 ,$18.95 ,
FOREARM SPLINT SMALL LEFT,12354,CDM,270,RC,,HCPCS,outpatient,,,$18.53 ,$6.49 ,,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.61 ,$17.60 ,
FOREARM SPLINT SMALL RIGHT,12774,CDM,270,RC,,HCPCS,outpatient,,,$18.53 ,$6.49 ,,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$13.90 ,75,,,percent of total billed charges,75% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges,$5.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.61 ,$17.60 ,
FOURFLEX MULTILAYER COMP SYSTEM,30062,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
FUNNEL FISTULA,20322,CDM,270,RC,,HCPCS,outpatient,,,$563.00 ,$197.05 ,,$301.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$301.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$422.25 ,75,,,percent of total billed charges,75% of total billed charges,$422.25 ,75,,,percent of total billed charges,75% of total billed charges,$422.25 ,75,,,percent of total billed charges,75% of total billed charges,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$450.40 ,80,,,percent of total billed charges,80% of total billed charges,$178.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$197.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$394.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$394.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$433.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$174.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$506.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$113.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$534.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$111.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$523.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$422.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$422.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$422.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$478.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.79 ,$534.85 ,
Felt Roll,30121,CDM,270,RC,,HCPCS,outpatient,,,$236.74 ,$82.86 ,,$126.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$177.56 ,75,,,percent of total billed charges,75% of total billed charges,$177.56 ,75,,,percent of total billed charges,75% of total billed charges,$177.56 ,75,,,percent of total billed charges,75% of total billed charges,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$189.39 ,80,,,percent of total billed charges,80% of total billed charges,$74.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$82.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$165.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$73.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$213.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$177.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$177.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$201.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.16 ,$224.90 ,
"Flex Connector 5.2""",28672,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Flow sensors VENT,30158,CDM,270,RC,,HCPCS,outpatient,,,$95.76 ,$33.52 ,,$51.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.82 ,75,,,percent of total billed charges,75% of total billed charges,$71.82 ,75,,,percent of total billed charges,75% of total billed charges,$71.82 ,75,,,percent of total billed charges,75% of total billed charges,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.61 ,80,,,percent of total billed charges,80% of total billed charges,$30.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.97 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.67 ,$90.97 ,
GAS SAMPLING LINE  967-ZML-9550,28666,CDM,270,RC,,HCPCS,outpatient,,,$10.29 ,$3.60 ,,$5.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.72 ,75,,,percent of total billed charges,75% of total billed charges,$7.72 ,75,,,percent of total billed charges,75% of total billed charges,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,80,,,percent of total billed charges,80% of total billed charges,$3.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.01 ,$9.78 ,
GAUZE 2 X 2 N/S,12135,CDM,270,RC,,HCPCS,outpatient,,,$7.00 ,$2.45 ,,$3.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$3.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$5.25 ,75,,,percent of total billed charges,75% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.60 ,80,,,percent of total billed charges,80% of total billed charges,$2.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$2.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$4.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$5.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$2.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$2.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$6.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$1.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$6.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$1.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$5.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.37 ,$6.65 ,
GAUZE 4 X 4 N/S,12136,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
GAUZE 4 X 4 STERILE,11063,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
GAUZE ROLL DERMACEA STRETCH 4X4,30037,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
GAUZE ROLL DERMACEA STRETCH 6X4,30038,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
GIA 80 4.8 MM Reloads,30197,CDM,270,RC,,HCPCS,outpatient,,,$353.60 ,$123.76 ,,$189.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$265.20 ,75,,,percent of total billed charges,75% of total billed charges,$265.20 ,75,,,percent of total billed charges,75% of total billed charges,$265.20 ,75,,,percent of total billed charges,75% of total billed charges,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.88 ,80,,,percent of total billed charges,80% of total billed charges,$111.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$272.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$318.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$71.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.92 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$265.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$265.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$265.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.95 ,$335.92 ,
GIA 80 4.8MM Stapler,30196,CDM,270,RC,,HCPCS,outpatient,,,$638.32 ,$223.41 ,,$342.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$342.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$478.74 ,75,,,percent of total billed charges,75% of total billed charges,$478.74 ,75,,,percent of total billed charges,75% of total billed charges,$478.74 ,75,,,percent of total billed charges,75% of total billed charges,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$510.66 ,80,,,percent of total billed charges,80% of total billed charges,$201.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$223.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$510.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$446.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$491.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$199.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$197.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$574.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$128.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$606.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$510.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$478.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$478.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$478.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$128.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$542.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$124.47 ,$606.40 ,
GIGLI SAW BLADE,11073,CDM,270,RC,,HCPCS,outpatient,,,$111.15 ,$38.90 ,,$59.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.36 ,75,,,percent of total billed charges,75% of total billed charges,$83.36 ,75,,,percent of total billed charges,75% of total billed charges,$83.36 ,75,,,percent of total billed charges,75% of total billed charges,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.92 ,80,,,percent of total billed charges,80% of total billed charges,$35.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$105.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.67 ,$105.59 ,
GLIDESCOPE LOPRO S3,28850,CDM,270,RC,,HCPCS,outpatient,,,$180.50 ,$63.18 ,,$96.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.40 ,80,,,percent of total billed charges,80% of total billed charges,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.48 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.20 ,$171.48 ,
GLIDESCOPE LOPRO S4,28851,CDM,270,RC,,HCPCS,outpatient,,,$180.50 ,$63.18 ,,$96.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$135.38 ,75,,,percent of total billed charges,75% of total billed charges,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.40 ,80,,,percent of total billed charges,80% of total billed charges,$57.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$162.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.48 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.20 ,$171.48 ,
GLIDESCOPE LOPRO S1,28869,CDM,270,RC,,HCPCS,outpatient,,,$221.00 ,$77.35 ,,$118.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$118.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$176.80 ,80,,,percent of total billed charges,80% of total billed charges,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$77.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$68.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$198.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.10 ,$209.95 ,
GLIDESCOPE LOPRO S2,28870,CDM,270,RC,,HCPCS,outpatient,,,$221.00 ,$77.35 ,,$118.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$118.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$165.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$176.80 ,80,,,percent of total billed charges,80% of total billed charges,$69.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$77.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$154.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$170.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$68.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$198.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$165.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.10 ,$209.95 ,
GRASPING FORCEPS,28403,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
GRIPPER NEEDLE 20 GA X 1 1/4,11581,CDM,270,RC,,HCPCS,outpatient,,,$22.49 ,$7.87 ,,$12.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.87 ,75,,,percent of total billed charges,75% of total billed charges,$16.87 ,75,,,percent of total billed charges,75% of total billed charges,$16.87 ,75,,,percent of total billed charges,75% of total billed charges,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.99 ,80,,,percent of total billed charges,80% of total billed charges,$7.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.12 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.39 ,$21.37 ,
GRIPPER NEEDLE 20 GA X 3/4,11884,CDM,270,RC,,HCPCS,outpatient,,,$17.51 ,$6.13 ,,$9.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.13 ,75,,,percent of total billed charges,75% of total billed charges,$13.13 ,75,,,percent of total billed charges,75% of total billed charges,$13.13 ,75,,,percent of total billed charges,75% of total billed charges,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.01 ,80,,,percent of total billed charges,80% of total billed charges,$5.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.01 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.41 ,$16.63 ,
GRIPPER POWER P.A.C. 1,12667,CDM,270,RC,,HCPCS,outpatient,,,$35.65 ,$12.48 ,,$19.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.74 ,75,,,percent of total billed charges,75% of total billed charges,$26.74 ,75,,,percent of total billed charges,75% of total billed charges,$26.74 ,75,,,percent of total billed charges,75% of total billed charges,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.52 ,80,,,percent of total billed charges,80% of total billed charges,$11.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.95 ,$33.87 ,
GRIPPER POWER P.A.C. 1 1/4,12668,CDM,270,RC,,HCPCS,outpatient,,,$53.81 ,$18.83 ,,$28.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.36 ,75,,,percent of total billed charges,75% of total billed charges,$40.36 ,75,,,percent of total billed charges,75% of total billed charges,$40.36 ,75,,,percent of total billed charges,75% of total billed charges,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.05 ,80,,,percent of total billed charges,80% of total billed charges,$17.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.49 ,$51.12 ,
GRIPPER POWER P.A.C. 3/4,12666,CDM,270,RC,,HCPCS,outpatient,,,$36.75 ,$12.86 ,,$19.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.56 ,75,,,percent of total billed charges,75% of total billed charges,$27.56 ,75,,,percent of total billed charges,75% of total billed charges,$27.56 ,75,,,percent of total billed charges,75% of total billed charges,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.40 ,80,,,percent of total billed charges,80% of total billed charges,$11.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.17 ,$34.91 ,
GROUNDING PAD  20 SQ. IN.,11067,CDM,270,RC,,HCPCS,outpatient,,,$20.43 ,$7.15 ,,$10.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.32 ,75,,,percent of total billed charges,75% of total billed charges,$15.32 ,75,,,percent of total billed charges,75% of total billed charges,$15.32 ,75,,,percent of total billed charges,75% of total billed charges,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.34 ,80,,,percent of total billed charges,80% of total billed charges,$6.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.33 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.98 ,$19.41 ,
GUIDERIGHT GUIDE WIRE,12639,CDM,270,RC,,HCPCS,outpatient,,,$70.88 ,$24.81 ,,$37.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.16 ,75,,,percent of total billed charges,75% of total billed charges,$53.16 ,75,,,percent of total billed charges,75% of total billed charges,$53.16 ,75,,,percent of total billed charges,75% of total billed charges,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.70 ,80,,,percent of total billed charges,80% of total billed charges,$22.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.81 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.79 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.82 ,$67.34 ,
Gastrostomy/Feeding Tube 18fr 3 port,30155,CDM,270,RC,,HCPCS,outpatient,,,$131.38 ,$45.98 ,,$70.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$98.54 ,75,,,percent of total billed charges,75% of total billed charges,$98.54 ,75,,,percent of total billed charges,75% of total billed charges,$98.54 ,75,,,percent of total billed charges,75% of total billed charges,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.10 ,80,,,percent of total billed charges,80% of total billed charges,$41.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$118.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$124.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$98.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$98.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$98.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.62 ,$124.81 ,
HAND MITT POSEY,12656,CDM,270,RC,,HCPCS,outpatient,,,$92.29 ,$32.30 ,,$49.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.22 ,75,,,percent of total billed charges,75% of total billed charges,$69.22 ,75,,,percent of total billed charges,75% of total billed charges,$69.22 ,75,,,percent of total billed charges,75% of total billed charges,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.83 ,80,,,percent of total billed charges,80% of total billed charges,$29.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.06 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.00 ,$87.68 ,
HARMONIC LAP 5MM SHEARS,12544,CDM,270,RC,,HCPCS,outpatient,,,"$2,958.49 ","$1,035.47 ",,"$1,585.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,585.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,366.79 ",80,,,percent of total billed charges,80% of total billed charges,$935.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,035.47 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,366.79 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,070.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,070.94 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,278.04 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$588.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$926.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$576.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$917.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,662.64 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$594.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,810.57 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,366.79 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$588.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,751.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,218.87 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$594.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,514.72 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$588.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$576.91 ,"$2,810.57 ",
HEAD SUPPORT,90534,CDM,272,RC,,HCPCS,outpatient,,,$31.87 ,$11.15 ,,$17.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.90 ,75,,,percent of total billed charges,75% of total billed charges,$23.90 ,75,,,percent of total billed charges,75% of total billed charges,$23.90 ,75,,,percent of total billed charges,75% of total billed charges,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.50 ,80,,,percent of total billed charges,80% of total billed charges,$10.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.21 ,$30.28 ,
HEMOVAC DRAIN FLAT SILICONE 10MM,12565,CDM,270,RC,,HCPCS,outpatient,,,$35.57 ,$12.45 ,,$19.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.68 ,75,,,percent of total billed charges,75% of total billed charges,$26.68 ,75,,,percent of total billed charges,75% of total billed charges,$26.68 ,75,,,percent of total billed charges,75% of total billed charges,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.46 ,80,,,percent of total billed charges,80% of total billed charges,$11.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.94 ,$33.79 ,
HEMOVAC DRAIN W/ TROCAR 1/4,11611,CDM,270,RC,,HCPCS,outpatient,,,$48.79 ,$17.08 ,,$26.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$36.59 ,75,,,percent of total billed charges,75% of total billed charges,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.03 ,80,,,percent of total billed charges,80% of total billed charges,$15.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.51 ,$46.35 ,
HEMOVAC DRAIN W/ TROCAR 3/32,11075,CDM,270,RC,,HCPCS,outpatient,,,$58.35 ,$20.42 ,,$31.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.76 ,75,,,percent of total billed charges,75% of total billed charges,$43.76 ,75,,,percent of total billed charges,75% of total billed charges,$43.76 ,75,,,percent of total billed charges,75% of total billed charges,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.68 ,80,,,percent of total billed charges,80% of total billed charges,$18.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.38 ,$55.43 ,
HEMOVAC MINI 100 ML,11262,CDM,270,RC,,HCPCS,outpatient,,,$62.90 ,$22.02 ,,$33.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.18 ,75,,,percent of total billed charges,75% of total billed charges,$47.18 ,75,,,percent of total billed charges,75% of total billed charges,$47.18 ,75,,,percent of total billed charges,75% of total billed charges,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.32 ,80,,,percent of total billed charges,80% of total billed charges,$19.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.02 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.27 ,$59.76 ,
HEMOVAC ROUND W/TROCAR & DRAIN,12782,CDM,270,RC,,HCPCS,outpatient,,,$67.44 ,$23.60 ,,$36.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.58 ,75,,,percent of total billed charges,75% of total billed charges,$50.58 ,75,,,percent of total billed charges,75% of total billed charges,$50.58 ,75,,,percent of total billed charges,75% of total billed charges,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.95 ,80,,,percent of total billed charges,80% of total billed charges,$21.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.15 ,$64.07 ,
HIBICLENS 4 OZ BOTTLE,CDM,CDM,270,RC,,HCPCS,outpatient,,,$95.00 ,$33.25 ,,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$71.25 ,75,,,percent of total billed charges,75% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges,$30.04 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.25 ,
HOSE KNEE LARGE,12355,CDM,270,RC,,HCPCS,outpatient,,,$22.03 ,$7.71 ,,$11.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.62 ,80,,,percent of total billed charges,80% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.30 ,$20.93 ,
HOSE KNEE MEDIUM,12356,CDM,270,RC,,HCPCS,outpatient,,,$14.07 ,$4.92 ,,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.37 ,
HOSE KNEE SMALL,12357,CDM,270,RC,,HCPCS,outpatient,,,$14.07 ,$4.92 ,,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.37 ,
HOSE KNEE X-LARGE,12358,CDM,270,RC,,HCPCS,outpatient,,,$22.03 ,$7.71 ,,$11.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$16.52 ,75,,,percent of total billed charges,75% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.62 ,80,,,percent of total billed charges,80% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.30 ,$20.93 ,
HOSE THIGH HI LARGE LONG,12359,CDM,270,RC,,HCPCS,outpatient,,,$14.07 ,$4.92 ,,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.37 ,
HOSE THIGH HI MED. LONG,12361,CDM,270,RC,,HCPCS,outpatient,,,$51.29 ,$17.95 ,,$27.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.47 ,75,,,percent of total billed charges,75% of total billed charges,$38.47 ,75,,,percent of total billed charges,75% of total billed charges,$38.47 ,75,,,percent of total billed charges,75% of total billed charges,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.03 ,80,,,percent of total billed charges,80% of total billed charges,$16.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$38.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.00 ,$48.73 ,
HOSE THIGH HI MED. REGULAR,12362,CDM,270,RC,,HCPCS,outpatient,,,$39.52 ,$13.83 ,,$21.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.64 ,75,,,percent of total billed charges,75% of total billed charges,$29.64 ,75,,,percent of total billed charges,75% of total billed charges,$29.64 ,75,,,percent of total billed charges,75% of total billed charges,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.62 ,80,,,percent of total billed charges,80% of total billed charges,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$35.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$29.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.71 ,$37.54 ,
HOSE THIGH HI SMALL REG. OR LONG,12363,CDM,270,RC,,HCPCS,outpatient,,,$14.07 ,$4.92 ,,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.37 ,
HOSE THIGH HI X-LARGE LONG,12364,CDM,270,RC,,HCPCS,outpatient,,,$45.62 ,$15.97 ,,$24.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.22 ,75,,,percent of total billed charges,75% of total billed charges,$34.22 ,75,,,percent of total billed charges,75% of total billed charges,$34.22 ,75,,,percent of total billed charges,75% of total billed charges,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.50 ,80,,,percent of total billed charges,80% of total billed charges,$14.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.06 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.90 ,$43.34 ,
HUMID FLO GIEBEK,12661,CDM,270,RC,,HCPCS,outpatient,,,$32.66 ,$11.43 ,,$17.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.50 ,75,,,percent of total billed charges,75% of total billed charges,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.13 ,80,,,percent of total billed charges,80% of total billed charges,$10.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.43 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$29.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.37 ,$31.03 ,
HYDROFERA BLUE READY FOAM DRESSING4X5,30063,CDM,270,RC,,HCPCS,outpatient,,,$30.95 ,$10.83 ,,$16.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.21 ,75,,,percent of total billed charges,75% of total billed charges,$23.21 ,75,,,percent of total billed charges,75% of total billed charges,$23.21 ,75,,,percent of total billed charges,75% of total billed charges,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.76 ,80,,,percent of total billed charges,80% of total billed charges,$9.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$27.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.04 ,$29.40 ,
HYDROFERA BLUE TRANSFER DRESSING 4X5,30089,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Handheld oximeter,19001,CDM,270,RC,,HCPCS,outpatient,,,"$1,087.52 ",$380.63 ,,$582.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$582.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$815.64 ,75,,,percent of total billed charges,75% of total billed charges,$815.64 ,75,,,percent of total billed charges,75% of total billed charges,$815.64 ,75,,,percent of total billed charges,75% of total billed charges,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$870.02 ,80,,,percent of total billed charges,80% of total billed charges,$343.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$380.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$870.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$761.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$837.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$337.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$978.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$218.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,033.14 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$216.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.39 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$815.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$815.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$815.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$924.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.07 ,"$1,033.14 ",
Harmonic lap shears 23 cm,28879,CDM,270,RC,,HCPCS,outpatient,,,"$2,702.99 ",$946.05 ,,"$1,448.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,448.80 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,162.39 ",80,,,percent of total billed charges,80% of total billed charges,$854.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$946.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,162.39 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,892.09 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,892.09 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,081.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$846.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$837.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,432.69 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$542.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,567.84 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,162.39 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$537.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,513.78 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,027.24 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$542.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,297.54 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$537.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$527.08 ,"$2,567.84 ",
Hose Thigh HI 2XL,92399,CDM,270,RC,,HCPCS,outpatient,,,$59.83 ,$20.94 ,,$32.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.87 ,75,,,percent of total billed charges,75% of total billed charges,$44.87 ,75,,,percent of total billed charges,75% of total billed charges,$44.87 ,75,,,percent of total billed charges,75% of total billed charges,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.86 ,80,,,percent of total billed charges,80% of total billed charges,$18.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.94 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.67 ,$56.84 ,
Humid vent filter,30231,CDM,270,RC,,HCPCS,outpatient,,,$13.25 ,$4.64 ,,$7.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.94 ,75,,,percent of total billed charges,75% of total billed charges,$9.94 ,75,,,percent of total billed charges,75% of total billed charges,$9.94 ,75,,,percent of total billed charges,75% of total billed charges,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.58 ,$12.59 ,
Humidification Chamber AH290,30259,CDM,270,RC,,HCPCS,outpatient,,,$41.48 ,$14.52 ,,$22.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.18 ,80,,,percent of total billed charges,80% of total billed charges,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.09 ,$39.41 ,
Hydrofera Blue Border Dressing 4x4,20346,CDM,270,RC,,HCPCS,outpatient,,,$42.40 ,$14.84 ,,$22.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.80 ,75,,,percent of total billed charges,75% of total billed charges,$31.80 ,75,,,percent of total billed charges,75% of total billed charges,$31.80 ,75,,,percent of total billed charges,75% of total billed charges,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.92 ,80,,,percent of total billed charges,80% of total billed charges,$13.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.27 ,$40.28 ,
I.V. INJECTION SITE,11235,CDM,270,RC,,HCPCS,outpatient,,,$11.77 ,$4.12 ,,$6.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.83 ,75,,,percent of total billed charges,75% of total billed charges,$8.83 ,75,,,percent of total billed charges,75% of total billed charges,$8.83 ,75,,,percent of total billed charges,75% of total billed charges,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.42 ,80,,,percent of total billed charges,80% of total billed charges,$3.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.30 ,$11.18 ,
I.V. START KIT,23013,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
INCENTIVE SPIROMETER,12019,CDM,410,RC,94010,HCPCS,outpatient,,,$246.72 ,$86.35 ,,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$222.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$234.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.11 ,$234.38 ,
INCISION AND DRAIN TRAY,12202,CDM,270,RC,,HCPCS,outpatient,,,$16.75 ,$5.86 ,,$8.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.56 ,75,,,percent of total billed charges,75% of total billed charges,$12.56 ,75,,,percent of total billed charges,75% of total billed charges,$12.56 ,75,,,percent of total billed charges,75% of total billed charges,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.40 ,80,,,percent of total billed charges,80% of total billed charges,$5.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.27 ,$15.91 ,
INFUSER DISP PRESSURE 1000CC,11551,CDM,270,RC,,HCPCS,outpatient,,,$52.16 ,$18.26 ,,$27.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.12 ,75,,,percent of total billed charges,75% of total billed charges,$39.12 ,75,,,percent of total billed charges,75% of total billed charges,$39.12 ,75,,,percent of total billed charges,75% of total billed charges,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.73 ,80,,,percent of total billed charges,80% of total billed charges,$16.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.17 ,$49.55 ,
INNER CANNULA SHILEY 7.5MM (6IC75),203206,CDM,270,RC,,HCPCS,outpatient,,,$14.64 ,$5.12 ,,$7.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.98 ,75,,,percent of total billed charges,75% of total billed charges,$10.98 ,75,,,percent of total billed charges,75% of total billed charges,$10.98 ,75,,,percent of total billed charges,75% of total billed charges,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.71 ,80,,,percent of total billed charges,80% of total billed charges,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.85 ,$13.91 ,
INSTRUMENT PURSTRING DISP 65,11589,CDM,270,RC,,HCPCS,outpatient,,,"$1,413.06 ",$494.57 ,,$757.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$757.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,130.45 ",80,,,percent of total billed charges,80% of total billed charges,$446.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$494.57 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,130.45 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$989.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$989.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.06 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$438.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,271.75 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$283.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,342.41 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,130.45 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,314.15 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,059.80 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$283.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,201.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$275.55 ,"$1,342.41 ",
INSUFFLATION NEEDLE 120MM,12539,CDM,270,RC,,HCPCS,outpatient,,,$82.78 ,$28.97 ,,$44.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.09 ,75,,,percent of total billed charges,75% of total billed charges,$62.09 ,75,,,percent of total billed charges,75% of total billed charges,$62.09 ,75,,,percent of total billed charges,75% of total billed charges,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.22 ,80,,,percent of total billed charges,80% of total billed charges,$26.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$74.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$62.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.14 ,$78.64 ,
INSUFFLATION TUBING HIGH FLOW,28677,CDM,270,RC,,HCPCS,outpatient,,,$246.72 ,$86.35 ,,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$222.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$234.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.11 ,$234.38 ,
INTERPULSE HANDPIECE W/SOFT TIP,12676,CDM,270,RC,,HCPCS,outpatient,,,$188.08 ,$65.83 ,,$100.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.06 ,75,,,percent of total billed charges,75% of total billed charges,$141.06 ,75,,,percent of total billed charges,75% of total billed charges,$141.06 ,75,,,percent of total billed charges,75% of total billed charges,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.46 ,80,,,percent of total billed charges,80% of total billed charges,$59.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.68 ,$178.68 ,
INTRAOSSEOUS ACCESS NEEDLE #16,11571,CDM,270,RC,,HCPCS,outpatient,,,$216.03 ,$75.61 ,,$115.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$115.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$162.02 ,75,,,percent of total billed charges,75% of total billed charges,$162.02 ,75,,,percent of total billed charges,75% of total billed charges,$162.02 ,75,,,percent of total billed charges,75% of total billed charges,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.82 ,80,,,percent of total billed charges,80% of total billed charges,$68.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$75.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$151.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$166.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$66.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$194.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$43.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$162.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$183.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.13 ,$205.23 ,
IPPB CIRCUIT W/NEBULIZER,12020,CDM,270,RC,,HCPCS,outpatient,,,"$1,487.50 ",$520.63 ,,$797.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$797.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,190.00 ",80,,,percent of total billed charges,80% of total billed charges,$470.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$520.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,190.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,041.25 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,041.25 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,145.38 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$290.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$461.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,338.75 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$298.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,413.13 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,190.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$295.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,383.38 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,264.38 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$290.06 ,"$1,413.13 ",
IRRIGATION TRAY,11086,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
IRRIGATOR LAP 0026870,93042,CDM,272,RC,,HCPCS,outpatient,,,$229.69 ,$80.39 ,,$123.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$172.27 ,75,,,percent of total billed charges,75% of total billed charges,$172.27 ,75,,,percent of total billed charges,75% of total billed charges,$172.27 ,75,,,percent of total billed charges,75% of total billed charges,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$183.75 ,80,,,percent of total billed charges,80% of total billed charges,$72.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$183.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$160.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$176.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$206.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$172.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$172.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$195.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.79 ,$218.21 ,
Inhalation Sterile Water 2000ML,30258,CDM,270,RC,,HCPCS,outpatient,,,$26.25 ,$9.19 ,,$14.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$19.69 ,75,,,percent of total billed charges,75% of total billed charges,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.00 ,80,,,percent of total billed charges,80% of total billed charges,$8.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.31 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.12 ,$24.94 ,
Inner Cannula Shiley 8DIC,28864,CDM,270,RC,,HCPCS,outpatient,,,$12.59 ,$4.41 ,,$6.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.44 ,75,,,percent of total billed charges,75% of total billed charges,$9.44 ,75,,,percent of total billed charges,75% of total billed charges,$9.44 ,75,,,percent of total billed charges,75% of total billed charges,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.07 ,80,,,percent of total billed charges,80% of total billed charges,$3.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.70 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.46 ,$11.96 ,
Intersurgical Superset Dbl Swivel Mount Bronchoscopy,12620,CDM,270,RC,,HCPCS,outpatient,,,$42.84 ,$14.99 ,,$22.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.13 ,75,,,percent of total billed charges,75% of total billed charges,$32.13 ,75,,,percent of total billed charges,75% of total billed charges,$32.13 ,75,,,percent of total billed charges,75% of total billed charges,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.27 ,80,,,percent of total billed charges,80% of total billed charges,$13.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.35 ,$40.70 ,
Intubating S-Guide Malleable,28720,CDM,270,RC,,HCPCS,outpatient,,,$132.05 ,$46.22 ,,$70.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.04 ,75,,,percent of total billed charges,75% of total billed charges,$99.04 ,75,,,percent of total billed charges,75% of total billed charges,$99.04 ,75,,,percent of total billed charges,75% of total billed charges,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.64 ,80,,,percent of total billed charges,80% of total billed charges,$41.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$46.22 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$118.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$125.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$99.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$99.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$112.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.75 ,$125.45 ,
Jejunal feeding tube,29945,CDM,270,RC,,HCPCS,outpatient,,,$880.28 ,$308.10 ,,$471.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$471.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$660.21 ,75,,,percent of total billed charges,75% of total billed charges,$660.21 ,75,,,percent of total billed charges,75% of total billed charges,$660.21 ,75,,,percent of total billed charges,75% of total billed charges,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$704.22 ,80,,,percent of total billed charges,80% of total billed charges,$278.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$308.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$704.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$616.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$616.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$677.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$275.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$272.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$792.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$176.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$836.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$175.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$818.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$660.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$660.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$660.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$176.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$748.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.65 ,$836.27 ,
K-WIRE .062,11555,CDM,270,RC,,HCPCS,outpatient,,,$31.51 ,$11.03 ,,$16.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.21 ,80,,,percent of total billed charges,80% of total billed charges,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.14 ,$29.93 ,
K-WIRE DE TROCAR POINT .054,12755,CDM,270,RC,,HCPCS,outpatient,,,$188.10 ,$65.84 ,,$100.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.08 ,75,,,percent of total billed charges,75% of total billed charges,$141.08 ,75,,,percent of total billed charges,75% of total billed charges,$141.08 ,75,,,percent of total billed charges,75% of total billed charges,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.48 ,80,,,percent of total billed charges,80% of total billed charges,$59.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$144.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$159.89 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.68 ,$178.70 ,
KERLIX 2.25 X 3 YD. ROLL STERILE,11324,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KERLIX 3.4 X 3.6 YD. ROLL STERILE,12672,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KERLIX 4.5 X 4.1 YD. ROLL STERILE,12673,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KERLIX 6 X 6 3/4 SPONGE STERILE,12674,CDM,270,RC,,HCPCS,outpatient,,,$10.97 ,$3.84 ,,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,75,,,percent of total billed charges,75% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges,$3.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.14 ,$10.42 ,
KIDNEY SHAPED BALLOON,12893,CDM,270,RC,,HCPCS,outpatient,,,"$1,461.00 ",$511.35 ,,$783.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$783.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,168.80 ",80,,,percent of total billed charges,80% of total billed charges,$461.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$511.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,168.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,022.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,022.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,124.97 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$290.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$457.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$452.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,314.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$293.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,387.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,168.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$290.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,358.73 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,095.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$293.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,241.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$290.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.90 ,"$1,387.95 ",
KLING 2,11101,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KLING 3,11089,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KLING 4,11102,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KLING 6,11103,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
KNEE SPLINT 14' UNIVERSAL,11741,CDM,274,RC,,HCPCS,outpatient,,,$48.67 ,$17.03 ,,$26.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$36.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.94 ,80,,,percent of total billed charges,80% of total billed charges,$15.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.49 ,$46.24 ,
KNEE SPLINT 20' UNIVERSAL,12490,CDM,270,RC,,HCPCS,outpatient,,,$61.11 ,$21.39 ,,$32.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.83 ,75,,,percent of total billed charges,75% of total billed charges,$45.83 ,75,,,percent of total billed charges,75% of total billed charges,$45.83 ,75,,,percent of total billed charges,75% of total billed charges,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.89 ,80,,,percent of total billed charges,80% of total billed charges,$19.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.89 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.92 ,$58.05 ,
Kerecis Omega3 MariGen 16mm Circ Disk,11803,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Kerecis Omega3 MariGen 16mm Disk,11803,CDM,270,RC,15271,HCPCS,outpatient,,,"$1,554.00 ",$543.90 ,,$832.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$832.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,243.20 ",80,,,percent of total billed charges,80% of total billed charges,$491.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$543.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,243.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,087.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,087.80 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,196.58 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$486.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$481.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,398.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$312.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,476.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,243.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$309.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,445.22 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,165.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,320.90 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.03 ,"$1,476.30 ",
LACERATION TRAY,11106,CDM,270,RC,,HCPCS,outpatient,,,$28.68 ,$10.04 ,,$15.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.51 ,75,,,percent of total billed charges,75% of total billed charges,$21.51 ,75,,,percent of total billed charges,75% of total billed charges,$21.51 ,75,,,percent of total billed charges,75% of total billed charges,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.94 ,80,,,percent of total billed charges,80% of total billed charges,$9.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$25.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.59 ,$27.25 ,
LAP SPONGE 18 X 18,11090,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
LAP SPONGE 4X18 STR,11701,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
LAPAROSCOPIC BOVIE ELECTRODE L-HOOK,12602,CDM,270,RC,,HCPCS,outpatient,,,$563.50 ,$197.23 ,,$302.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$302.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$422.63 ,75,,,percent of total billed charges,75% of total billed charges,$422.63 ,75,,,percent of total billed charges,75% of total billed charges,$422.63 ,75,,,percent of total billed charges,75% of total billed charges,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$450.80 ,80,,,percent of total billed charges,80% of total billed charges,$178.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$197.23 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$394.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$394.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$433.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$176.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$176.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$174.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$507.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$113.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$535.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$112.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$422.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$422.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$422.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$478.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.88 ,$535.33 ,
LAPRASCOPIC CHOL BALLON CATH SET,90647,CDM,272,RC,,HCPCS,outpatient,,,$386.42 ,$135.25 ,,$207.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$207.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$289.82 ,75,,,percent of total billed charges,75% of total billed charges,$289.82 ,75,,,percent of total billed charges,75% of total billed charges,$289.82 ,75,,,percent of total billed charges,75% of total billed charges,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.14 ,80,,,percent of total billed charges,80% of total billed charges,$122.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$135.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$309.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$270.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$297.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$119.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$347.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$77.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$367.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$359.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$289.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$289.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$289.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$328.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.35 ,$367.10 ,
LEAD WIRES FOR CARDIAC MONITOR (see 90318),90648,CDM,270,RC,,HCPCS,outpatient,,,$377.83 ,$132.24 ,,$202.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$202.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$283.37 ,75,,,percent of total billed charges,75% of total billed charges,$283.37 ,75,,,percent of total billed charges,75% of total billed charges,$283.37 ,75,,,percent of total billed charges,75% of total billed charges,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.26 ,80,,,percent of total billed charges,80% of total billed charges,$119.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$132.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$302.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$264.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$290.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$117.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$340.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$75.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$358.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$302.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$351.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$283.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$283.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$283.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$321.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.68 ,$358.94 ,
LEG BAG,11092,CDM,270,RC,,HCPCS,outpatient,,,$14.04 ,$4.91 ,,$7.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.53 ,75,,,percent of total billed charges,75% of total billed charges,$10.53 ,75,,,percent of total billed charges,75% of total billed charges,$10.53 ,75,,,percent of total billed charges,75% of total billed charges,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,80,,,percent of total billed charges,80% of total billed charges,$4.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.64 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.34 ,
LESION MARKER 10mm XACT,90649,CDM,270,RC,,HCPCS,outpatient,,,$160.31 ,$56.11 ,,$85.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.93 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.23 ,75,,,percent of total billed charges,75% of total billed charges,$120.23 ,75,,,percent of total billed charges,75% of total billed charges,$120.23 ,75,,,percent of total billed charges,75% of total billed charges,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.25 ,80,,,percent of total billed charges,80% of total billed charges,$50.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.28 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.26 ,$152.29 ,
LEVER LOCK CANNULA,11892,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
LIFEBAND for ZOLL AUTOPULSE,12795,CDM,270,RC,,HCPCS,outpatient,,,$485.00 ,$169.75 ,,$259.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$259.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$363.75 ,75,,,percent of total billed charges,75% of total billed charges,$363.75 ,75,,,percent of total billed charges,75% of total billed charges,$363.75 ,75,,,percent of total billed charges,75% of total billed charges,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$388.00 ,80,,,percent of total billed charges,80% of total billed charges,$153.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$169.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$388.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$339.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$373.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$150.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$436.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$97.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$460.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$388.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$451.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$363.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$363.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$97.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$412.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.58 ,$460.75 ,
"LIMB HOLDER, WRIST/ANKLE",12655,CDM,270,RC,,HCPCS,outpatient,,,$199.64 ,$69.87 ,,$107.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$149.73 ,75,,,percent of total billed charges,75% of total billed charges,$149.73 ,75,,,percent of total billed charges,75% of total billed charges,$149.73 ,75,,,percent of total billed charges,75% of total billed charges,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$159.71 ,80,,,percent of total billed charges,80% of total billed charges,$63.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$153.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$179.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$149.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$149.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.93 ,$189.66 ,
LOADING UNIT M/F GIA 60-3.8,11339,CDM,270,RC,,HCPCS,outpatient,,,$241.91 ,$84.67 ,,$129.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$129.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$181.43 ,75,,,percent of total billed charges,75% of total billed charges,$181.43 ,75,,,percent of total billed charges,75% of total billed charges,$181.43 ,75,,,percent of total billed charges,75% of total billed charges,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$193.53 ,80,,,percent of total billed charges,80% of total billed charges,$76.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$84.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$169.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$186.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$74.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$217.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$229.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$181.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$181.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$181.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$205.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.17 ,$229.81 ,
LOADING UNIT M/F TA 60-3.5,11664,CDM,270,RC,,HCPCS,outpatient,,,$232.99 ,$81.55 ,,$124.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.74 ,75,,,percent of total billed charges,75% of total billed charges,$174.74 ,75,,,percent of total billed charges,75% of total billed charges,$174.74 ,75,,,percent of total billed charges,75% of total billed charges,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.39 ,80,,,percent of total billed charges,80% of total billed charges,$73.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$186.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$163.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$72.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$209.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$221.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$174.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$198.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.43 ,$221.34 ,
LOADING UNIT MULTIFIRE 90-3.5,12750,CDM,270,RC,,HCPCS,outpatient,,,$329.63 ,$115.37 ,,$176.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$176.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$247.22 ,75,,,percent of total billed charges,75% of total billed charges,$247.22 ,75,,,percent of total billed charges,75% of total billed charges,$247.22 ,75,,,percent of total billed charges,75% of total billed charges,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$263.70 ,80,,,percent of total billed charges,80% of total billed charges,$104.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$115.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$263.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$253.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$103.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$102.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$296.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$313.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$247.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$247.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$247.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.28 ,$313.15 ,
LOADING UNIT PREM 90-4.8,11665,CDM,270,RC,,HCPCS,outpatient,,,"$1,134.00 ",$396.90 ,,$607.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$607.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$850.50 ,75,,,percent of total billed charges,75% of total billed charges,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$907.20 ,80,,,percent of total billed charges,80% of total billed charges,$358.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$396.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$793.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$793.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$873.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$355.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$221.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$351.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,020.60 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$227.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,077.30 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,054.62 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$850.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$227.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$963.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$225.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$221.13 ,"$1,077.30 ",
LUER LOCK ADAPTER MALE,11958,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
LUKERS TUBE 3 1/4 X 8 MM,11654,CDM,270,RC,,HCPCS,outpatient,,,$28.07 ,$9.82 ,,$15.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.05 ,75,,,percent of total billed charges,75% of total billed charges,$21.05 ,75,,,percent of total billed charges,75% of total billed charges,$21.05 ,75,,,percent of total billed charges,75% of total billed charges,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.46 ,80,,,percent of total billed charges,80% of total billed charges,$8.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$25.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.47 ,$26.67 ,
LUMBAR PUNCTURE TRAY ADULT,11154,CDM,270,RC,,HCPCS,outpatient,,,$82.16 ,$28.76 ,,$44.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$61.62 ,75,,,percent of total billed charges,75% of total billed charges,$61.62 ,75,,,percent of total billed charges,75% of total billed charges,$61.62 ,75,,,percent of total billed charges,75% of total billed charges,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.73 ,80,,,percent of total billed charges,80% of total billed charges,$25.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$73.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$78.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.02 ,$78.05 ,
LUMBAR PUNCTURE TRAY PED.,11155,CDM,270,RC,,HCPCS,outpatient,,,$231.84 ,$81.14 ,,$124.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.88 ,75,,,percent of total billed charges,75% of total billed charges,$173.88 ,75,,,percent of total billed charges,75% of total billed charges,$173.88 ,75,,,percent of total billed charges,75% of total billed charges,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$185.47 ,80,,,percent of total billed charges,80% of total billed charges,$73.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$81.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$185.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$197.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.21 ,$220.25 ,
LYSOL SPRAY 19 OZ.,CDM,CDM,270,RC,,HCPCS,outpatient,,,$36.91 ,$12.92 ,,$19.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.68 ,75,,,percent of total billed charges,75% of total billed charges,$27.68 ,75,,,percent of total billed charges,75% of total billed charges,$27.68 ,75,,,percent of total billed charges,75% of total billed charges,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.53 ,80,,,percent of total billed charges,80% of total billed charges,$11.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.20 ,$35.06 ,
MALECOT DRAIN 18 FR.,12702,CDM,270,RC,,HCPCS,outpatient,,,$116.57 ,$40.80 ,,$62.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.43 ,75,,,percent of total billed charges,75% of total billed charges,$87.43 ,75,,,percent of total billed charges,75% of total billed charges,$87.43 ,75,,,percent of total billed charges,75% of total billed charges,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.26 ,80,,,percent of total billed charges,80% of total billed charges,$36.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$89.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$104.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.73 ,$110.74 ,
MASK AEROSOL LONG PEDS,11823,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK ANESTHESIA  CHILD,12811,CDM,270,RC,,HCPCS,outpatient,,,$10.18 ,$3.56 ,,$5.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.14 ,80,,,percent of total billed charges,80% of total billed charges,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.99 ,$9.67 ,
MASK ANESTHESIA  MED ADULT,12812,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK ANESTHESIA  TODDLER,12813,CDM,270,RC,,HCPCS,outpatient,,,$10.18 ,$3.56 ,,$5.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$7.64 ,75,,,percent of total billed charges,75% of total billed charges,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.14 ,80,,,percent of total billed charges,80% of total billed charges,$3.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.99 ,$9.67 ,
MASK ELONGATED O2 MED. CONCENTRIC,11614,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK LARGE w/ HEADGEAR,12412,CDM,270,RC,,HCPCS,outpatient,,,$104.31 ,$36.51 ,,$55.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.23 ,75,,,percent of total billed charges,75% of total billed charges,$78.23 ,75,,,percent of total billed charges,75% of total billed charges,$78.23 ,75,,,percent of total billed charges,75% of total billed charges,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.45 ,80,,,percent of total billed charges,80% of total billed charges,$32.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$80.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$93.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$78.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$78.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.34 ,$99.09 ,
MASK MED W/ HEADGEAR,12411,CDM,270,RC,,HCPCS,outpatient,,,$74.58 ,$26.10 ,,$39.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.94 ,75,,,percent of total billed charges,75% of total billed charges,$55.94 ,75,,,percent of total billed charges,75% of total billed charges,$55.94 ,75,,,percent of total billed charges,75% of total billed charges,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.66 ,80,,,percent of total billed charges,80% of total billed charges,$23.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.54 ,$70.85 ,
MASK MULTI VENT ADULT,11620,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK MULTI VENT PEDS,11824,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK NON REBREATHING PEDS,11822,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MASK PERFORMAX SPU LARGE,12617,CDM,270,RC,,HCPCS,outpatient,,,$168.96 ,$59.14 ,,$90.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.56 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.72 ,75,,,percent of total billed charges,75% of total billed charges,$126.72 ,75,,,percent of total billed charges,75% of total billed charges,$126.72 ,75,,,percent of total billed charges,75% of total billed charges,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.17 ,80,,,percent of total billed charges,80% of total billed charges,$53.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$118.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$52.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$152.06 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$126.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$126.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$143.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.95 ,$160.51 ,
MASK PERFORMAX SPU SMALL,12618,CDM,270,RC,,HCPCS,outpatient,,,$178.46 ,$62.46 ,,$95.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$95.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$133.85 ,75,,,percent of total billed charges,75% of total billed charges,$133.85 ,75,,,percent of total billed charges,75% of total billed charges,$133.85 ,75,,,percent of total billed charges,75% of total billed charges,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$142.77 ,80,,,percent of total billed charges,80% of total billed charges,$56.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$62.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$142.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$137.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$55.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$160.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$169.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$133.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.80 ,$169.54 ,
MASK SMALL W/ HEADGEAR,17055,CDM,270,RC,,HCPCS,outpatient,,,$102.13 ,$35.75 ,,$54.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.60 ,75,,,percent of total billed charges,75% of total billed charges,$76.60 ,75,,,percent of total billed charges,75% of total billed charges,$76.60 ,75,,,percent of total billed charges,75% of total billed charges,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.70 ,80,,,percent of total billed charges,80% of total billed charges,$32.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.92 ,$97.02 ,
MASTISOL ADHESIVE 2/3 CC,30072,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MATRIX FENESTRATED WOUND 3 X 4 CM,93092,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MEDICINE CUPS PLASTIC,CDM,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
MEDIGRIP ELASTICATED TUBULAR BANDAGE SZ C 2 5/8X 11 YD,30042,CDM,270,RC,,HCPCS,outpatient,,,$101.37 ,$35.48 ,,$54.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.03 ,75,,,percent of total billed charges,75% of total billed charges,$76.03 ,75,,,percent of total billed charges,75% of total billed charges,$76.03 ,75,,,percent of total billed charges,75% of total billed charges,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.10 ,80,,,percent of total billed charges,80% of total billed charges,$32.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.42 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.77 ,$96.30 ,
MEDIGRIP ELASTICATED TUBULAR BANDAGE SZ E 3.5 X 11 YD,30044,CDM,270,RC,,HCPCS,outpatient,,,$179.92 ,$62.97 ,,$96.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$134.94 ,75,,,percent of total billed charges,75% of total billed charges,$134.94 ,75,,,percent of total billed charges,75% of total billed charges,$134.94 ,75,,,percent of total billed charges,75% of total billed charges,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$143.94 ,80,,,percent of total billed charges,80% of total billed charges,$56.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$62.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$143.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$161.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$170.92 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$143.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$134.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$134.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$134.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.08 ,$170.92 ,
"MEDIGRIP ELASTICATED TUBULAR BANDAGE SZ F 4"" X 11 YD",30045,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
MEDIGRIP ELASTICATED TUBULAR BANDAGE SZ G 4-3/4 X 11 YD,30046,CDM,270,RC,,HCPCS,outpatient,,,$164.83 ,$57.69 ,,$88.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.62 ,75,,,percent of total billed charges,75% of total billed charges,$123.62 ,75,,,percent of total billed charges,75% of total billed charges,$123.62 ,75,,,percent of total billed charges,75% of total billed charges,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.86 ,80,,,percent of total billed charges,80% of total billed charges,$52.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.69 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.38 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$148.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$123.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.78 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.14 ,$156.59 ,
"MEDIGRIP TUBULAR BANDAGE SZ D 3"" X 11 YD",30043,CDM,270,RC,,HCPCS,outpatient,,,$111.96 ,$39.19 ,,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.97 ,75,,,percent of total billed charges,75% of total billed charges,$83.97 ,75,,,percent of total billed charges,75% of total billed charges,$83.97 ,75,,,percent of total billed charges,75% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.57 ,80,,,percent of total billed charges,80% of total billed charges,$35.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.83 ,$106.36 ,
MESH 3D MAX LARGE LEFT,12556,CDM,278,RC,,HCPCS,both,,,"$1,067.50 ",$373.63 ,,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$373.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$821.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$334.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$330.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$960.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,014.13 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.16 ,"$1,014.13 ",
MESH 3D MAX LARGE RIGHT,12557,CDM,278,RC,,HCPCS,both,,,"$1,067.50 ",$373.63 ,,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$373.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$821.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$334.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$330.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$960.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,014.13 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.16 ,"$1,014.13 ",
MESH 3D MAX MED. LEFT,12607,CDM,278,RC,,HCPCS,both,,,"$1,067.50 ",$373.63 ,,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$373.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$821.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$334.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$330.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$960.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,014.13 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.16 ,"$1,014.13 ",
MESH 3D MAX MED. RIGHT,12608,CDM,278,RC,,HCPCS,both,,,"$1,067.50 ",$373.63 ,,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$572.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$800.63 ,75,,,percent of total billed charges,75% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges,$337.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$373.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$747.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$821.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$334.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$330.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$960.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,014.13 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$992.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$800.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$214.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$907.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$208.16 ,"$1,014.13 ",
MESH PROLENE 3 X 6,12699,CDM,278,RC,,HCPCS,both,,,$697.89 ,$244.26 ,,$374.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$374.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$523.42 ,75,,,percent of total billed charges,75% of total billed charges,$523.42 ,75,,,percent of total billed charges,75% of total billed charges,$523.42 ,75,,,percent of total billed charges,75% of total billed charges,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$558.31 ,80,,,percent of total billed charges,80% of total billed charges,$220.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$244.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$558.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$488.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$488.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$537.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$216.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$628.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$140.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$663.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$558.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$649.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$523.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$523.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$523.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$140.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$593.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.09 ,$663.00 ,
MESH PROLENE 6 X 6,11816,CDM,278,RC,,HCPCS,both,,,$772.24 ,$270.28 ,,$413.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$413.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$579.18 ,75,,,percent of total billed charges,75% of total billed charges,$579.18 ,75,,,percent of total billed charges,75% of total billed charges,$579.18 ,75,,,percent of total billed charges,75% of total billed charges,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$617.79 ,80,,,percent of total billed charges,80% of total billed charges,$244.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$270.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$617.79 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$540.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$540.57 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$594.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$241.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$241.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$241.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$239.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$695.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$155.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$733.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$617.79 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$153.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$718.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$579.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$579.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$579.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$155.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$656.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.59 ,$733.63 ,
MESH SEPRA 3 x 6,12614,CDM,278,RC,,HCPCS,both,,,"$2,439.00 ",$853.65 ,,"$1,307.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,307.30 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,951.20 ",80,,,percent of total billed charges,80% of total billed charges,$771.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$853.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,951.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,707.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,707.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,878.03 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$485.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$763.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$475.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$756.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,195.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$489.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,317.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,951.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$485.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,268.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,829.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$489.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,073.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$485.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$475.61 ,"$2,317.05 ",
MESH SEPRA 4 X 8,12555,CDM,278,RC,,HCPCS,both,,,"$3,789.00 ","$1,326.15 ",,"$2,030.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,030.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,031.20 ",80,,,percent of total billed charges,80% of total billed charges,"$1,198.08 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,326.15 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,031.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,652.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,652.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,917.53 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,186.34 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$738.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,174.59 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,410.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$760.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,599.55 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,031.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$753.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,523.77 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,841.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$760.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,220.65 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$753.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$738.86 ,"$3,599.55 ",
MESH SEPRA 6 X 8,12554,CDM,278,RC,,HCPCS,both,,,"$5,382.00 ","$1,883.70 ",,"$2,884.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,884.75 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,305.60 ",80,,,percent of total billed charges,80% of total billed charges,"$1,701.79 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,883.70 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,305.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,767.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,767.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,144.14 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,070.48 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,685.10 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,049.49 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,668.42 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,843.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,080.71 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,112.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,305.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,070.48 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,005.26 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,036.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,080.71 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,574.70 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,070.48 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,049.49 ","$5,112.90 ",
MICKEY FEEDING TUBE 20F 3.5CM,30252,CDM,270,RC,,HCPCS,outpatient,,,$409.76 ,$143.42 ,,$219.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$219.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$307.32 ,75,,,percent of total billed charges,75% of total billed charges,$307.32 ,75,,,percent of total billed charges,75% of total billed charges,$307.32 ,75,,,percent of total billed charges,75% of total billed charges,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$327.81 ,80,,,percent of total billed charges,80% of total billed charges,$129.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$143.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$327.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$286.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$286.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$315.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$368.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$389.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$327.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$381.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$307.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$307.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$348.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.90 ,$389.27 ,
MINI-SPIKE DESPENSING PIN,90655,CDM,270,RC,,HCPCS,outpatient,,,$12.80 ,$4.48 ,,$6.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.60 ,75,,,percent of total billed charges,75% of total billed charges,$9.60 ,75,,,percent of total billed charges,75% of total billed charges,$9.60 ,75,,,percent of total billed charges,75% of total billed charges,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.24 ,80,,,percent of total billed charges,80% of total billed charges,$4.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.50 ,$12.16 ,
MONARCH I CARTRIDGE,90472,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MONARCH II CARTRIDGE C,90473,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MONARCH III CARTRIDGE,90474,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
MONOFILAMENTS DIABETIC NUEROPATH,30026,CDM,270,RC,,HCPCS,outpatient,,,$16.86 ,$5.90 ,,$9.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.65 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,75,,,percent of total billed charges,75% of total billed charges,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.49 ,80,,,percent of total billed charges,80% of total billed charges,$5.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.29 ,$16.02 ,
MORGAN LENS,11774,CDM,270,RC,,HCPCS,outpatient,,,$227.67 ,$79.68 ,,$122.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$170.75 ,75,,,percent of total billed charges,75% of total billed charges,$170.75 ,75,,,percent of total billed charges,75% of total billed charges,$170.75 ,75,,,percent of total billed charges,75% of total billed charges,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$182.14 ,80,,,percent of total billed charges,80% of total billed charges,$71.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$182.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$159.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$175.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$71.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$204.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$216.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$170.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$170.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.40 ,$216.29 ,
Mask Airlife 02 Med,20307,CDM,270,RC,,HCPCS,outpatient,,,$35.83 ,$12.54 ,,$19.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.87 ,75,,,percent of total billed charges,75% of total billed charges,$26.87 ,75,,,percent of total billed charges,75% of total billed charges,$26.87 ,75,,,percent of total billed charges,75% of total billed charges,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.66 ,80,,,percent of total billed charges,80% of total billed charges,$11.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.54 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.99 ,$34.04 ,
Mask Antifog,11323,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Medihoney Wound Dress 4 x 5,300100,CDM,637,RC,,HCPCS,outpatient,,,$45.04 ,$15.76 ,,$24.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.78 ,75,,,percent of total billed charges,75% of total billed charges,$33.78 ,75,,,percent of total billed charges,75% of total billed charges,$33.78 ,75,,,percent of total billed charges,75% of total billed charges,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.03 ,80,,,percent of total billed charges,80% of total billed charges,$14.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.79 ,
"Medipore Tape 4""",NS874,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Microlyte Polymeric Film 2x2,20312,CDM,272,RC,,HCPCS,outpatient,,,$192.50 ,$67.38 ,,$103.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$144.38 ,75,,,percent of total billed charges,75% of total billed charges,$144.38 ,75,,,percent of total billed charges,75% of total billed charges,$144.38 ,75,,,percent of total billed charges,75% of total billed charges,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$154.00 ,80,,,percent of total billed charges,80% of total billed charges,$60.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.38 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$59.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$173.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$144.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.38 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$163.63 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.54 ,$182.88 ,
NASAL CANNULA PEDS,11727,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NEEDLE BIOPSY 2N2704X,93010,CDM,272,RC,,HCPCS,outpatient,,,$101.60 ,$35.56 ,,$54.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.20 ,75,,,percent of total billed charges,75% of total billed charges,$76.20 ,75,,,percent of total billed charges,75% of total billed charges,$76.20 ,75,,,percent of total billed charges,75% of total billed charges,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.28 ,80,,,percent of total billed charges,80% of total billed charges,$32.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.81 ,$96.52 ,
NEEDLE GRIPPER PLUS 19G X 3/4,93103,CDM,272,RC,,HCPCS,outpatient,,,$22.73 ,$7.96 ,,$12.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.05 ,75,,,percent of total billed charges,75% of total billed charges,$17.05 ,75,,,percent of total billed charges,75% of total billed charges,$17.05 ,75,,,percent of total billed charges,75% of total billed charges,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.18 ,80,,,percent of total billed charges,80% of total billed charges,$7.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.43 ,$21.59 ,
NIPPLE & NUT ADAPTER,11626,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NITRO GLYEREN SET,23023,CDM,270,RC,,HCPCS,outpatient,,,$25.94 ,$9.08 ,,$13.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.46 ,75,,,percent of total billed charges,75% of total billed charges,$19.46 ,75,,,percent of total billed charges,75% of total billed charges,$19.46 ,75,,,percent of total billed charges,75% of total billed charges,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.75 ,80,,,percent of total billed charges,80% of total billed charges,$8.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.06 ,$24.64 ,
NPWT KIT PICO 7x7  W/ PUMP,30070,CDM,270,RC,,HCPCS,outpatient,,,$949.17 ,$332.21 ,,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$332.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$730.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$297.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$294.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$854.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$901.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$882.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$185.09 ,$901.71 ,
NPWT PICO 7 W/PUMP 10x30,30207,CDM,270,RC,,HCPCS,outpatient,,,$949.17 ,$332.21 ,,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$332.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$730.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$297.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$294.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$854.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$901.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$882.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$185.09 ,$901.71 ,
NU TRAKE KIT PEDS,11812,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NU TRAKE KITADULT,11811,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE IDOFORM 1,12163,CDM,270,RC,,HCPCS,outpatient,,,$10.34 ,$3.62 ,,$5.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.27 ,80,,,percent of total billed charges,80% of total billed charges,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.27 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.62 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.02 ,$9.82 ,
NUGAUZE IDOFORM 1/4,12161,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE IDOFORM 1/2,12162,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE IDOFORM 2,12164,CDM,270,RC,,HCPCS,outpatient,,,$14.18 ,$4.96 ,,$7.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.64 ,75,,,percent of total billed charges,75% of total billed charges,$10.64 ,75,,,percent of total billed charges,75% of total billed charges,$10.64 ,75,,,percent of total billed charges,75% of total billed charges,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.34 ,80,,,percent of total billed charges,80% of total billed charges,$4.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.77 ,$13.47 ,
NUGAUZE PLAIN 1,12159,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE PLAIN 1/2,12158,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE PLAIN 1/4,12157,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
NUGAUZE PLAIN 2,12160,CDM,270,RC,,HCPCS,outpatient,,,$12.39 ,$4.34 ,,$6.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.29 ,75,,,percent of total billed charges,75% of total billed charges,$9.29 ,75,,,percent of total billed charges,75% of total billed charges,$9.29 ,75,,,percent of total billed charges,75% of total billed charges,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.91 ,80,,,percent of total billed charges,80% of total billed charges,$3.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.42 ,$11.77 ,
NUSHIELD 2 X 3,30243,CDM,272,RC,,HCPCS,outpatient,,,"$2,385.00 ",$834.75 ,,"$1,278.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,278.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,908.00 ",80,,,percent of total billed charges,80% of total billed charges,$754.14 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$834.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,908.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,669.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,669.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,836.45 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$474.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$746.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$739.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,146.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$478.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,265.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,908.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$474.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,218.05 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,788.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$478.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,027.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$474.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$465.08 ,"$2,265.75 ",
NUSHIELD 2 X 4,30240,CDM,272,RC,,HCPCS,outpatient,,,"$2,850.00 ",$997.50 ,,"$1,527.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,527.60 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,280.00 ",80,,,percent of total billed charges,80% of total billed charges,$901.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$997.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,995.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,995.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,194.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$566.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$892.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$555.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$883.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,565.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$572.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,707.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,280.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$566.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,650.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,137.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$572.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,422.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$566.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$555.75 ,"$2,707.50 ",
NUSHIELD 6 X 6,30244,CDM,272,RC,,HCPCS,outpatient,,,"$10,650.00 ","$3,727.50 ",,"$5,708.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,708.40 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$8,520.00 ",80,,,percent of total billed charges,80% of total billed charges,"$3,367.53 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,727.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,520.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,455.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,455.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,200.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,118.29 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,334.52 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,076.75 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,301.50 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$9,585.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,138.52 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$10,117.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,520.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,118.29 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,904.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,987.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,138.52 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,052.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,118.29 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,076.75 ","$10,117.50 ",
Nomoline Adapter Adult w/O2 Tubing,11950,CDM,270,RC,,HCPCS,outpatient,,,$53.00 ,$18.55 ,,$28.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.75 ,75,,,percent of total billed charges,75% of total billed charges,$39.75 ,75,,,percent of total billed charges,75% of total billed charges,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.40 ,80,,,percent of total billed charges,80% of total billed charges,$16.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$47.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.34 ,$50.35 ,
O2 MASK HIGH CONCENT. NON REBREATHER,11615,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
O2 SENSOR MAXA  ADULT,28567,CDM,270,RC,,HCPCS,outpatient,,,$27.28 ,$9.55 ,,$14.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.46 ,75,,,percent of total billed charges,75% of total billed charges,$20.46 ,75,,,percent of total billed charges,75% of total billed charges,$20.46 ,75,,,percent of total billed charges,75% of total billed charges,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.82 ,80,,,percent of total billed charges,80% of total billed charges,$8.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.92 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.32 ,$25.92 ,
O2 SENSOR MAXN  NEONATE,12442,CDM,270,RC,,HCPCS,outpatient,,,$35.47 ,$12.41 ,,$19.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.60 ,75,,,percent of total billed charges,75% of total billed charges,$26.60 ,75,,,percent of total billed charges,75% of total billed charges,$26.60 ,75,,,percent of total billed charges,75% of total billed charges,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.38 ,80,,,percent of total billed charges,80% of total billed charges,$11.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.92 ,$33.70 ,
O2 SENSOR REFLECTANCE (FOREHEAD),11930,CDM,270,RC,,HCPCS,outpatient,,,$63.16 ,$22.11 ,,$33.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.37 ,75,,,percent of total billed charges,75% of total billed charges,$47.37 ,75,,,percent of total billed charges,75% of total billed charges,$47.37 ,75,,,percent of total billed charges,75% of total billed charges,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.53 ,80,,,percent of total billed charges,80% of total billed charges,$19.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.32 ,$60.00 ,
ON-Q ELECTROSURGICAL NEEDLE,12711,CDM,270,RC,,HCPCS,outpatient,,,$90.83 ,$31.79 ,,$48.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.68 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.12 ,75,,,percent of total billed charges,75% of total billed charges,$68.12 ,75,,,percent of total billed charges,75% of total billed charges,$68.12 ,75,,,percent of total billed charges,75% of total billed charges,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$72.66 ,80,,,percent of total billed charges,80% of total billed charges,$28.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$81.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$68.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$68.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.71 ,$86.29 ,
ON-Q PREP TRAY,12710,CDM,270,RC,,HCPCS,outpatient,,,$297.50 ,$104.13 ,,$159.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$159.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$223.13 ,75,,,percent of total billed charges,75% of total billed charges,$223.13 ,75,,,percent of total billed charges,75% of total billed charges,$223.13 ,75,,,percent of total billed charges,75% of total billed charges,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$238.00 ,80,,,percent of total billed charges,80% of total billed charges,$94.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$104.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$238.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$208.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$229.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$92.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$267.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$282.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$223.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$223.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$223.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$252.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.01 ,$282.63 ,
OPTICELL AG+ SILVER ANTIB GELL 0.75 X 18,30028,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
OPTICELL AG+ SILVER GELLING FIBER 4X5,30027,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
OPTICELL AG+SILVER 6X6,30067,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
OPTICELL GELLING FIBER DRESSING 4.25X4.25,30055,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
OPTICELL GELLING FIBER DRESSING 6X6,30056,CDM,270,RC,,HCPCS,outpatient,,,$26.30 ,$9.21 ,,$14.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.73 ,75,,,percent of total billed charges,75% of total billed charges,$19.73 ,75,,,percent of total billed charges,75% of total billed charges,$19.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.04 ,80,,,percent of total billed charges,80% of total billed charges,$8.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.13 ,$24.99 ,
OPTIFOAM GENTLE EX SACRUM 7X7,30031,CDM,270,RC,,HCPCS,outpatient,,,$17.16 ,$6.01 ,,$9.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$12.87 ,75,,,percent of total billed charges,75% of total billed charges,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.73 ,80,,,percent of total billed charges,80% of total billed charges,$5.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.59 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.35 ,$16.30 ,
OPTIFOAM GENTLE LITE WOUND DRESS BORDER 6X6,30068,CDM,270,RC,,HCPCS,outpatient,,,$22.67 ,$7.93 ,,$12.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.14 ,80,,,percent of total billed charges,80% of total billed charges,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.42 ,$21.54 ,
OPTIFOAM GENTLE SILICONE BORDER 4X4,30029,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
OPTIFOAM GENTLE SILICONE FACED FOAM 6X6,30030,CDM,270,RC,,HCPCS,outpatient,,,$62.80 ,$21.98 ,,$33.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.10 ,75,,,percent of total billed charges,75% of total billed charges,$47.10 ,75,,,percent of total billed charges,75% of total billed charges,$47.10 ,75,,,percent of total billed charges,75% of total billed charges,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.24 ,80,,,percent of total billed charges,80% of total billed charges,$19.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.24 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.25 ,$59.66 ,
OPTILOCK NONADH SUPER ABSORB DRESSING 4X4,30032,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
OPTILOCK NONADH SUPER ABSORB DRESSING 8X12,30033,CDM,270,RC,,HCPCS,outpatient,,,$21.04 ,$7.36 ,,$11.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.78 ,75,,,percent of total billed charges,75% of total billed charges,$15.78 ,75,,,percent of total billed charges,75% of total billed charges,$15.78 ,75,,,percent of total billed charges,75% of total billed charges,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.83 ,80,,,percent of total billed charges,80% of total billed charges,$6.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.10 ,$19.99 ,
OPTILOCK NONADH SUPER ABSORB DRESSING 6.5 X 10,30091,CDM,270,RC,,HCPCS,outpatient,,,$21.98 ,$7.69 ,,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.69 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.29 ,$20.88 ,
ORAL AIRWAY 60MM,28663,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
ORAL AIRWAY 70MM,28664,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
OVAL EYE PAD,11070,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
OXYGEN TUBING 7',12045,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
OXYTIP SENSOR ADULT,11691,CDM,270,RC,,HCPCS,outpatient,,,$58.38 ,$20.43 ,,$31.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.79 ,75,,,percent of total billed charges,75% of total billed charges,$43.79 ,75,,,percent of total billed charges,75% of total billed charges,$43.79 ,75,,,percent of total billed charges,75% of total billed charges,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.70 ,80,,,percent of total billed charges,80% of total billed charges,$18.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.43 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.38 ,$55.46 ,
Optifoam Gentle  Silicone Faced 4x4 (Non- Border),30097,CDM,270,RC,,HCPCS,outpatient,,,$11.81 ,$4.13 ,,$6.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.86 ,75,,,percent of total billed charges,75% of total billed charges,$8.86 ,75,,,percent of total billed charges,75% of total billed charges,$8.86 ,75,,,percent of total billed charges,75% of total billed charges,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,80,,,percent of total billed charges,80% of total billed charges,$3.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.30 ,$11.22 ,
Ortho Glass Splint,20288,CDM,270,RC,,HCPCS,outpatient,,,$65.00 ,$22.75 ,,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$48.75 ,75,,,percent of total billed charges,75% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$58.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.68 ,$61.75 ,
P.C.A. SET,11401,CDM,270,RC,,HCPCS,outpatient,,,$27.56 ,$9.65 ,,$14.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.67 ,75,,,percent of total billed charges,75% of total billed charges,$20.67 ,75,,,percent of total billed charges,75% of total billed charges,$20.67 ,75,,,percent of total billed charges,75% of total billed charges,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.05 ,80,,,percent of total billed charges,80% of total billed charges,$8.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.37 ,$26.18 ,
PAD ABDOMINAL CURITY 8X10 STERILE,30021,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PARACENTESIS TRAY,11905,CDM,270,RC,,HCPCS,outpatient,,,$328.74 ,$115.06 ,,$176.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$176.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$246.56 ,75,,,percent of total billed charges,75% of total billed charges,$246.56 ,75,,,percent of total billed charges,75% of total billed charges,$246.56 ,75,,,percent of total billed charges,75% of total billed charges,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$262.99 ,80,,,percent of total billed charges,80% of total billed charges,$103.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$115.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$262.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$230.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$253.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$295.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$312.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$262.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$305.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$246.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$246.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$279.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.10 ,$312.30 ,
PASTE 1/2 OZ TUBE,11264,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PATIENT INDEX CARDS,90670,CDM,270,RC,,HCPCS,outpatient,,,$103.69 ,$36.29 ,,$55.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.77 ,75,,,percent of total billed charges,75% of total billed charges,$77.77 ,75,,,percent of total billed charges,75% of total billed charges,$77.77 ,75,,,percent of total billed charges,75% of total billed charges,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.95 ,80,,,percent of total billed charges,80% of total billed charges,$32.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.29 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$93.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$77.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.22 ,$98.51 ,
PATIENT PHONES,90669,CDM,270,RC,,HCPCS,outpatient,,,"$1,190.00 ",$416.50 ,,$637.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$637.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$892.50 ,75,,,percent of total billed charges,75% of total billed charges,$892.50 ,75,,,percent of total billed charges,75% of total billed charges,$892.50 ,75,,,percent of total billed charges,75% of total billed charges,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$952.00 ,80,,,percent of total billed charges,80% of total billed charges,$376.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$416.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$952.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$833.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$916.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$368.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,071.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$238.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,130.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$952.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$236.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,106.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$892.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$892.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$892.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$238.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,011.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$232.05 ,"$1,130.50 ",
"PCA Y-SET 86""",30163,CDM,270,RC,,HCPCS,outpatient,,,$26.04 ,$9.11 ,,$13.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.53 ,75,,,percent of total billed charges,75% of total billed charges,$19.53 ,75,,,percent of total billed charges,75% of total billed charges,$19.53 ,75,,,percent of total billed charges,75% of total billed charges,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.83 ,80,,,percent of total billed charges,80% of total billed charges,$8.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.08 ,$24.74 ,
PED-U BAG,11214,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PEDI CATH KIT 5fr,11791,CDM,270,RC,,HCPCS,outpatient,,,$14.22 ,$4.98 ,,$7.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$10.67 ,75,,,percent of total billed charges,75% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges,$4.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.77 ,$13.51 ,
PEDS BAG 1L LF,12575,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PEDS BAG 2L LF,12576,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PEG 20fr. (boston scifi),28922,CDM,270,RC,,HCPCS,outpatient,,,$492.76 ,$172.47 ,,$264.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$369.57 ,75,,,percent of total billed charges,75% of total billed charges,$369.57 ,75,,,percent of total billed charges,75% of total billed charges,$369.57 ,75,,,percent of total billed charges,75% of total billed charges,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$394.21 ,80,,,percent of total billed charges,80% of total billed charges,$155.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$172.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$394.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$344.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$344.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$379.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$154.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$154.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$152.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$443.48 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$98.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$468.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$394.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$458.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$369.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$369.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$369.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$98.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$418.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.09 ,$468.12 ,
PEN ROSE DRAIN,11098,CDM,270,RC,,HCPCS,outpatient,,,$10.64 ,$3.72 ,,$5.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,80,,,percent of total billed charges,80% of total billed charges,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.07 ,$10.11 ,
PERCUTANEOUS ENTRY NEEDLE,12636,CDM,270,RC,,HCPCS,outpatient,,,$67.46 ,$23.61 ,,$36.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.60 ,75,,,percent of total billed charges,75% of total billed charges,$50.60 ,75,,,percent of total billed charges,75% of total billed charges,$50.60 ,75,,,percent of total billed charges,75% of total billed charges,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.97 ,80,,,percent of total billed charges,80% of total billed charges,$21.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.15 ,$64.09 ,
PERCUTANEOUS SHEATH INTRO KIT 8.5,11199,CDM,270,RC,,HCPCS,outpatient,,,$138.46 ,$48.46 ,,$74.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.85 ,75,,,percent of total billed charges,75% of total billed charges,$103.85 ,75,,,percent of total billed charges,75% of total billed charges,$103.85 ,75,,,percent of total billed charges,75% of total billed charges,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.77 ,80,,,percent of total billed charges,80% of total billed charges,$43.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$124.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.69 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.00 ,$131.54 ,
PERITINEAL LAVAGE KIT 8 FR,11548,CDM,270,RC,,HCPCS,outpatient,,,$231.20 ,$80.92 ,,$123.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$123.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$173.40 ,75,,,percent of total billed charges,75% of total billed charges,$173.40 ,75,,,percent of total billed charges,75% of total billed charges,$173.40 ,75,,,percent of total billed charges,75% of total billed charges,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$184.96 ,80,,,percent of total billed charges,80% of total billed charges,$73.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$80.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$178.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$71.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$208.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$46.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$219.64 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$215.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$173.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$173.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$196.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.08 ,$219.64 ,
PICC KIT 5F DUAL LUMEN 50CM,30120,CDM,270,RC,,HCPCS,outpatient,,,$778.68 ,$272.54 ,,$417.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$417.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$584.01 ,75,,,percent of total billed charges,75% of total billed charges,$584.01 ,75,,,percent of total billed charges,75% of total billed charges,$584.01 ,75,,,percent of total billed charges,75% of total billed charges,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$622.94 ,80,,,percent of total billed charges,80% of total billed charges,$246.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$272.54 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$622.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$545.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$545.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$599.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$243.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$241.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$700.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$156.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$739.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$724.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$584.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$584.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$156.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$661.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$151.84 ,$739.75 ,
PICC KIT 5F DUAL LUMEN IR 70CM NITINOL GW,12498,CDM,270,RC,,HCPCS,outpatient,,,$546.40 ,$191.24 ,,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$292.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$409.80 ,75,,,percent of total billed charges,75% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges,$172.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$191.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$382.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$420.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$171.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$169.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$491.76 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$519.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$437.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$508.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$409.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$464.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.55 ,$519.08 ,
PICO 7 25X25 CM,30234,CDM,272,RC,,HCPCS,outpatient,,,$949.17 ,$332.21 ,,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$332.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$730.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$297.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$294.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$854.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$901.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$882.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$185.09 ,$901.71 ,
PLASTER GYP 4 X 4 YD,11817,CDM,270,RC,,HCPCS,outpatient,,,$23.26 ,$8.14 ,,$12.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.45 ,75,,,percent of total billed charges,75% of total billed charges,$17.45 ,75,,,percent of total billed charges,75% of total billed charges,$17.45 ,75,,,percent of total billed charges,75% of total billed charges,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.61 ,80,,,percent of total billed charges,80% of total billed charges,$7.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.77 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.54 ,$22.10 ,
PLEUREVAC,11105,CDM,270,RC,,HCPCS,outpatient,,,$188.73 ,$66.06 ,,$101.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$101.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.55 ,75,,,percent of total billed charges,75% of total billed charges,$141.55 ,75,,,percent of total billed charges,75% of total billed charges,$141.55 ,75,,,percent of total billed charges,75% of total billed charges,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$150.98 ,80,,,percent of total billed charges,80% of total billed charges,$59.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$66.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$59.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$58.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$169.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$175.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$141.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$141.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$160.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.80 ,$179.29 ,
PLUG MESH,28920,CDM,270,RC,,HCPCS,outpatient,,,$644.40 ,$225.54 ,,$345.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$345.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$483.30 ,75,,,percent of total billed charges,75% of total billed charges,$483.30 ,75,,,percent of total billed charges,75% of total billed charges,$483.30 ,75,,,percent of total billed charges,75% of total billed charges,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$515.52 ,80,,,percent of total billed charges,80% of total billed charges,$203.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$225.54 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$515.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$451.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$451.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$496.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$201.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$199.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$579.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$129.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$612.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$599.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$483.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$483.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$483.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$129.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$547.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.66 ,$612.18 ,
PNEUMOTHORAX SET,28634,CDM,270,RC,,HCPCS,outpatient,,,$853.16 ,$298.61 ,,$457.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$457.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$639.87 ,75,,,percent of total billed charges,75% of total billed charges,$639.87 ,75,,,percent of total billed charges,75% of total billed charges,$639.87 ,75,,,percent of total billed charges,75% of total billed charges,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$682.53 ,80,,,percent of total billed charges,80% of total billed charges,$269.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$298.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$682.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$597.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$597.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$656.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$267.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$264.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$767.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$171.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$810.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$169.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$793.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$639.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$639.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$639.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$171.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$725.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$166.37 ,$810.50 ,
POLYP TRAP,28400,CDM,270,RC,,HCPCS,outpatient,,,$31.50 ,$11.03 ,,$16.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$23.63 ,75,,,percent of total billed charges,75% of total billed charges,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.20 ,80,,,percent of total billed charges,80% of total billed charges,$9.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.14 ,$29.93 ,
PONSKY PULL SILICONE PEG TRAY 20FR,11365,CDM,270,RC,,HCPCS,outpatient,,,$263.75 ,$92.31 ,,$141.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$141.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$197.81 ,75,,,percent of total billed charges,75% of total billed charges,$197.81 ,75,,,percent of total billed charges,75% of total billed charges,$197.81 ,75,,,percent of total billed charges,75% of total billed charges,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$211.00 ,80,,,percent of total billed charges,80% of total billed charges,$83.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$92.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$211.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$184.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$203.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$237.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.56 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$211.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$197.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$197.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$197.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$224.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.43 ,$250.56 ,
PORT-A CATH TRAY TITANIUM,11422,CDM,270,RC,,HCPCS,outpatient,,,"$1,402.35 ",$490.82 ,,$751.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$751.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,121.88 ",80,,,percent of total billed charges,80% of total billed charges,$443.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$490.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,121.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$981.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$981.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,079.81 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$439.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$273.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$434.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,262.12 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$281.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,332.23 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,121.88 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$278.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,304.19 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,051.76 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$281.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,192.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$273.46 ,"$1,332.23 ",
PORT-A-CATH NEEDLE 20 X 3/4 GRIPPER,12819,CDM,270,RC,,HCPCS,outpatient,,,$28.88 ,$10.11 ,,$15.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.66 ,75,,,percent of total billed charges,75% of total billed charges,$21.66 ,75,,,percent of total billed charges,75% of total billed charges,$21.66 ,75,,,percent of total billed charges,75% of total billed charges,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.10 ,80,,,percent of total billed charges,80% of total billed charges,$9.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$25.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.63 ,$27.44 ,
PORT-A-CATH NEEDLE 22 X 1  90 DEGREE,11552,CDM,270,RC,,HCPCS,outpatient,,,$16.63 ,$5.82 ,,$8.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.47 ,75,,,percent of total billed charges,75% of total billed charges,$12.47 ,75,,,percent of total billed charges,75% of total billed charges,$12.47 ,75,,,percent of total billed charges,75% of total billed charges,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.30 ,80,,,percent of total billed charges,80% of total billed charges,$5.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.97 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.24 ,$15.80 ,
PORT-A-CATH SUBCLAVIN INT.,11576,CDM,270,RC,,HCPCS,outpatient,,,$161.60 ,$56.56 ,,$86.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.20 ,75,,,percent of total billed charges,75% of total billed charges,$121.20 ,75,,,percent of total billed charges,75% of total billed charges,$121.20 ,75,,,percent of total billed charges,75% of total billed charges,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$129.28 ,80,,,percent of total billed charges,80% of total billed charges,$51.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$145.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$153.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.51 ,$153.52 ,
PORTEX TRACHEAL TUBE INTRODUCER,12803,CDM,270,RC,,HCPCS,outpatient,,,$225.86 ,$79.05 ,,$121.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.40 ,75,,,percent of total billed charges,75% of total billed charges,$169.40 ,75,,,percent of total billed charges,75% of total billed charges,$169.40 ,75,,,percent of total billed charges,75% of total billed charges,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$180.69 ,80,,,percent of total billed charges,80% of total billed charges,$71.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$180.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$158.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$203.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$214.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$169.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$169.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$169.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$191.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.04 ,$214.57 ,
POST OF SHOE RT,11904,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
POWER PORT 8 FR,12595,CDM,270,RC,,HCPCS,outpatient,,,"$2,149.50 ",$752.33 ,,"$1,152.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,152.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,719.60 ",80,,,percent of total billed charges,80% of total billed charges,$679.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$752.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,719.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,504.65 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,504.65 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,655.12 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$673.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$419.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$666.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,934.55 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$431.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,042.03 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,719.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$427.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,999.04 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,612.13 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$431.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,827.08 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$427.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$419.15 ,"$2,042.03 ",
PPH CIRCULAR STAPLER SET,12543,CDM,270,RC,,HCPCS,outpatient,,,"$1,500.92 ",$525.32 ,,$804.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$804.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,200.74 ",80,,,percent of total billed charges,80% of total billed charges,$474.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$525.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,200.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,050.64 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,050.64 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,155.71 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$469.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$465.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,350.83 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$301.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,425.87 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,395.86 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,125.69 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$301.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,275.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$292.68 ,"$1,425.87 ",
PREP PAD PVP-I MEDIUM,30090,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PRESSURE PAD ALT,12814,CDM,272,RC,,HCPCS,outpatient,,,$224.49 ,$78.57 ,,$120.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$168.37 ,75,,,percent of total billed charges,75% of total billed charges,$168.37 ,75,,,percent of total billed charges,75% of total billed charges,$168.37 ,75,,,percent of total billed charges,75% of total billed charges,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$179.59 ,80,,,percent of total billed charges,80% of total billed charges,$70.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.57 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$202.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$213.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$208.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$168.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$168.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$190.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.78 ,$213.27 ,
PRESSURE TRANSDUCER KIT,11250,CDM,270,RC,,HCPCS,outpatient,,,$235.63 ,$82.47 ,,$126.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$126.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$176.72 ,75,,,percent of total billed charges,75% of total billed charges,$176.72 ,75,,,percent of total billed charges,75% of total billed charges,$176.72 ,75,,,percent of total billed charges,75% of total billed charges,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$188.50 ,80,,,percent of total billed charges,80% of total billed charges,$74.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$82.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$188.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$164.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$181.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$73.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$212.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$47.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$223.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$176.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$176.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$176.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.95 ,$223.85 ,
PROBE GENERAL PURPOSE 9FR 400 SERIES,28675,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
PROTACH 5MM FIXATION DEVICE,12587,CDM,270,RC,,HCPCS,outpatient,,,"$2,338.17 ",$818.36 ,,"$1,253.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,253.26 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,870.54 ",80,,,percent of total billed charges,80% of total billed charges,$739.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$818.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,870.54 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,636.72 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,636.72 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,800.39 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$732.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$455.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$724.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,104.35 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$469.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,221.26 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,870.54 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$465.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,174.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,753.63 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$469.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,987.44 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$455.94 ,"$2,221.26 ",
PURACOL PLUS AG+COLLAGEN DRESSING W/ SILVER,30069,CDM,270,RC,,HCPCS,outpatient,,,$99.89 ,$34.96 ,,$53.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.92 ,75,,,percent of total billed charges,75% of total billed charges,$74.92 ,75,,,percent of total billed charges,75% of total billed charges,$74.92 ,75,,,percent of total billed charges,75% of total billed charges,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.91 ,80,,,percent of total billed charges,80% of total billed charges,$31.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$89.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$74.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.48 ,$94.90 ,
Pad Heat Therapy K 18 X 24,11932,CDM,270,RC,,HCPCS,outpatient,,,$30.45 ,$10.66 ,,$16.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.84 ,75,,,percent of total billed charges,75% of total billed charges,$22.84 ,75,,,percent of total billed charges,75% of total billed charges,$22.84 ,75,,,percent of total billed charges,75% of total billed charges,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,80,,,percent of total billed charges,80% of total billed charges,$9.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$27.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.94 ,$28.93 ,
"Pad, Oasis, Tri Layer, 3x3.5 cm",30148,CDM,270,RC,,HCPCS,outpatient,,,$800.98 ,$280.34 ,,$429.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$429.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$600.74 ,75,,,percent of total billed charges,75% of total billed charges,$600.74 ,75,,,percent of total billed charges,75% of total billed charges,$600.74 ,75,,,percent of total billed charges,75% of total billed charges,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$640.78 ,80,,,percent of total billed charges,80% of total billed charges,$253.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$280.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$640.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$560.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$616.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$250.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$248.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$720.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$160.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$760.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$640.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$159.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$744.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$600.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$600.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$160.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$680.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.19 ,$760.93 ,
Pico 7 10x20 cm,30235,CDM,272,RC,,HCPCS,outpatient,,,$949.17 ,$332.21 ,,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$508.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$711.88 ,75,,,percent of total billed charges,75% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges,$300.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$332.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$664.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$730.86 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$297.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$297.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$185.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$294.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$854.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$901.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$759.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$882.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$711.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$190.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$806.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$185.09 ,$901.71 ,
"Plug, catheter drainage tube",30152,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Primatrix 14 MM,30194,CDM,272,RC,,HCPCS,outpatient,,,"$1,358.00 ",$475.30 ,,$727.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$727.89 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,086.40 ",80,,,percent of total billed charges,80% of total billed charges,$429.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$475.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,086.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$950.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$950.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,045.66 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$420.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,222.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$272.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,290.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,086.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$270.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,262.94 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,018.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$272.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,154.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$270.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$264.81 ,"$1,290.10 ",
Primatrix 18MM,30193,CDM,272,RC,,HCPCS,outpatient,,,"$1,652.00 ",$578.20 ,,$885.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$885.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,321.60 ",80,,,percent of total billed charges,80% of total billed charges,$522.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$578.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,321.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,156.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,156.40 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,272.04 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$517.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$322.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$512.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,486.80 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$331.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,569.40 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,321.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$328.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,536.36 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,239.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$331.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,404.20 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$322.14 ,"$1,569.40 ",
Primatrix 5x5,30195,CDM,272,RC,,HCPCS,outpatient,,,"$4,382.70 ","$1,533.95 ",,"$2,349.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,349.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,506.16 ",80,,,percent of total billed charges,80% of total billed charges,"$1,385.81 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,533.95 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,372.22 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,506.16 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,067.89 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,067.89 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,374.68 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,372.23 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$871.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,372.22 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,372.22 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,372.22 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,372.22 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$854.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,358.64 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,944.43 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$880.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,163.57 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,506.16 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$871.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,075.91 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,287.03 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$880.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,725.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$871.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$854.63 ,"$4,163.57 ",
Primatrix Meshed 8x8,30183,CDM,272,RC,,HCPCS,outpatient,,,"$10,267.98 ","$3,593.79 ",,"$5,503.64 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,503.64 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$8,214.38 ",80,,,percent of total billed charges,80% of total billed charges,"$3,246.74 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,593.79 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,214.38 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,187.59 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,187.59 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,906.34 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,042.30 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,214.90 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,002.26 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,183.07 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$9,241.18 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,061.81 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,754.58 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,214.38 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,042.30 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,549.22 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,700.99 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,061.81 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,727.78 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,042.30 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,002.26 ","$9,754.58 ",
Prisma AG+Collagen (promogran),30181,CDM,272,RC,,HCPCS,outpatient,,,$35.56 ,$12.45 ,,$19.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.67 ,75,,,percent of total billed charges,75% of total billed charges,$26.67 ,75,,,percent of total billed charges,75% of total billed charges,$26.67 ,75,,,percent of total billed charges,75% of total billed charges,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.45 ,80,,,percent of total billed charges,80% of total billed charges,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.89 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.89 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.93 ,$33.78 ,
Puraply AM 2x4,30213,CDM,272,RC,,HCPCS,outpatient,,,"$17,820.00 ","$6,237.00 ",,"$9,551.52 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$9,551.52 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$14,256.00 ",80,,,percent of total billed charges,80% of total billed charges,"$5,634.68 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$6,237.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$14,256.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$12,474.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$12,474.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$13,721.40 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,544.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,579.44 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,474.90 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$5,524.20 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$16,038.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$3,578.26 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$16,929.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$14,256.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,544.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$16,572.60 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$13,365.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,578.26 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$15,147.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,544.40 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,474.90 ","$16,929.00 ",
Q CARE CLEANING & SUCTIONING SYSTEM,11964,CDM,270,RC,,HCPCS,outpatient,,,$51.06 ,$17.87 ,,$27.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.30 ,75,,,percent of total billed charges,75% of total billed charges,$38.30 ,75,,,percent of total billed charges,75% of total billed charges,$38.30 ,75,,,percent of total billed charges,75% of total billed charges,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.85 ,80,,,percent of total billed charges,80% of total billed charges,$16.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$38.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.96 ,$48.51 ,
QuickTrach 4.0MM,30182,CDM,270,RC,,HCPCS,outpatient,,,$171.10 ,$59.89 ,,$91.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$91.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$128.33 ,75,,,percent of total billed charges,75% of total billed charges,$128.33 ,75,,,percent of total billed charges,75% of total billed charges,$128.33 ,75,,,percent of total billed charges,75% of total billed charges,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.88 ,80,,,percent of total billed charges,80% of total billed charges,$54.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$59.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$131.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$53.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$153.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$162.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$128.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$128.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$128.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.36 ,$162.55 ,
RAYTEC 4 X 4 STR. GAUZE,90102,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
RECTAL TUBE 20 LONG 22FR,11276,CDM,270,RC,,HCPCS,outpatient,,,$62.18 ,$21.76 ,,$33.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.64 ,75,,,percent of total billed charges,75% of total billed charges,$46.64 ,75,,,percent of total billed charges,75% of total billed charges,$46.64 ,75,,,percent of total billed charges,75% of total billed charges,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.74 ,80,,,percent of total billed charges,80% of total billed charges,$19.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.13 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.13 ,$59.07 ,
RESTRAINT JACKET SMALL,90680,CDM,270,RC,,HCPCS,outpatient,,,$64.16 ,$22.46 ,,$34.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.12 ,75,,,percent of total billed charges,75% of total billed charges,$48.12 ,75,,,percent of total billed charges,75% of total billed charges,$48.12 ,75,,,percent of total billed charges,75% of total billed charges,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.33 ,80,,,percent of total billed charges,80% of total billed charges,$20.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$57.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.51 ,$60.95 ,
RESTRAINT WRIST AND ANKLE ADULT,11636,CDM,270,RC,,HCPCS,outpatient,,,$53.13 ,$18.60 ,,$28.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.85 ,75,,,percent of total billed charges,75% of total billed charges,$39.85 ,75,,,percent of total billed charges,75% of total billed charges,$39.85 ,75,,,percent of total billed charges,75% of total billed charges,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.50 ,80,,,percent of total billed charges,80% of total billed charges,$16.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.19 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$47.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.36 ,$50.47 ,
RESUSCITATOR BAG W/PEEP VALVE,93076,CDM,272,RC,,HCPCS,outpatient,,,$95.03 ,$33.26 ,,$50.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.27 ,75,,,percent of total billed charges,75% of total billed charges,$71.27 ,75,,,percent of total billed charges,75% of total billed charges,$71.27 ,75,,,percent of total billed charges,75% of total billed charges,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.02 ,80,,,percent of total billed charges,80% of total billed charges,$30.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.53 ,$90.28 ,
RESUSCITATORS DISP. INFANT W/ MASK,11729,CDM,270,RC,,HCPCS,outpatient,,,$85.63 ,$29.97 ,,$45.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.22 ,75,,,percent of total billed charges,75% of total billed charges,$64.22 ,75,,,percent of total billed charges,75% of total billed charges,$64.22 ,75,,,percent of total billed charges,75% of total billed charges,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.50 ,80,,,percent of total billed charges,80% of total billed charges,$27.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$59.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.70 ,$81.35 ,
RESUSCITATORS DISP. CHILD W/ MASK,11728,CDM,270,RC,,HCPCS,outpatient,,,$45.33 ,$15.87 ,,$24.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$34.00 ,75,,,percent of total billed charges,75% of total billed charges,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.26 ,80,,,percent of total billed charges,80% of total billed charges,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.84 ,$43.06 ,
RESUSCITATORS DISP. ADULT W/ MASK,11321,CDM,270,RC,,HCPCS,outpatient,,,$93.92 ,$32.87 ,,$50.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.44 ,75,,,percent of total billed charges,75% of total billed charges,$70.44 ,75,,,percent of total billed charges,75% of total billed charges,$70.44 ,75,,,percent of total billed charges,75% of total billed charges,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$75.14 ,80,,,percent of total billed charges,80% of total billed charges,$29.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.12 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$84.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$89.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.31 ,$89.22 ,
RHINO ROCKET 5.5,12491,CDM,270,RC,,HCPCS,outpatient,,,$202.34 ,$70.82 ,,$108.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$151.76 ,75,,,percent of total billed charges,75% of total billed charges,$151.76 ,75,,,percent of total billed charges,75% of total billed charges,$151.76 ,75,,,percent of total billed charges,75% of total billed charges,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.87 ,80,,,percent of total billed charges,80% of total billed charges,$63.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$70.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$161.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$141.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$155.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$63.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$182.11 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$192.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$151.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$151.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$171.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.46 ,$192.22 ,
RHINO ROCKET 7.5,12492,CDM,270,RC,,HCPCS,outpatient,,,$208.52 ,$72.98 ,,$111.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$111.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$156.39 ,75,,,percent of total billed charges,75% of total billed charges,$156.39 ,75,,,percent of total billed charges,75% of total billed charges,$156.39 ,75,,,percent of total billed charges,75% of total billed charges,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$166.82 ,80,,,percent of total billed charges,80% of total billed charges,$65.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$72.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$166.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$145.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$160.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.66 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$187.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$41.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$198.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$166.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$193.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$156.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$156.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$156.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$177.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.66 ,$198.09 ,
ROCKER SWITCH PENCIL & HOLSTER,12589,CDM,270,RC,,HCPCS,outpatient,,,$18.32 ,$6.41 ,,$9.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.74 ,75,,,percent of total billed charges,75% of total billed charges,$13.74 ,75,,,percent of total billed charges,75% of total billed charges,$13.74 ,75,,,percent of total billed charges,75% of total billed charges,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.66 ,80,,,percent of total billed charges,80% of total billed charges,$5.79 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.57 ,$17.40 ,
ROTH NET RETRIEVING DEVICE,11952,CDM,270,RC,,HCPCS,outpatient,,,$399.50 ,$139.83 ,,$214.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$214.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$299.63 ,75,,,percent of total billed charges,75% of total billed charges,$299.63 ,75,,,percent of total billed charges,75% of total billed charges,$299.63 ,75,,,percent of total billed charges,75% of total billed charges,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.60 ,80,,,percent of total billed charges,80% of total billed charges,$126.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$139.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$319.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$279.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$307.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$125.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$123.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$359.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$80.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$379.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$319.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$371.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$299.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$299.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$339.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.46 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.90 ,$379.53 ,
ROTICULATOR ENDO DISSECT 5MM,11410,CDM,270,RC,,HCPCS,outpatient,,,$417.56 ,$146.15 ,,$223.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$223.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$313.17 ,75,,,percent of total billed charges,75% of total billed charges,$313.17 ,75,,,percent of total billed charges,75% of total billed charges,$313.17 ,75,,,percent of total billed charges,75% of total billed charges,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$334.05 ,80,,,percent of total billed charges,80% of total billed charges,$132.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$146.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$334.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$292.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$292.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$321.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$130.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$129.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$375.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$396.68 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$334.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$388.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$313.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$313.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$313.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$354.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.42 ,$396.68 ,
SALEM SUMP TUBE 10 FR,12224,CDM,270,RC,,HCPCS,outpatient,,,$15.77 ,$5.52 ,,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.08 ,$14.98 ,
SALEM SUMP TUBE 12 FR,12225,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SALEM SUMP TUBE 14 FR,12226,CDM,270,RC,,HCPCS,outpatient,,,$10.35 ,$3.62 ,,$5.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$7.76 ,75,,,percent of total billed charges,75% of total billed charges,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.28 ,80,,,percent of total billed charges,80% of total billed charges,$3.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.02 ,$9.83 ,
SALEM SUMP TUBE 16 FR,12227,CDM,270,RC,,HCPCS,outpatient,,,$15.77 ,$5.52 ,,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.08 ,$14.98 ,
SALEM SUMP TUBE 18 FR,12228,CDM,270,RC,,HCPCS,outpatient,,,$15.77 ,$5.52 ,,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$11.83 ,75,,,percent of total billed charges,75% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges,$4.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.14 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.83 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.17 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.08 ,$14.98 ,
SALEM SUMP TUBE 6 FR,12406,CDM,270,RC,,HCPCS,outpatient,,,$36.97 ,$12.94 ,,$19.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,80,,,percent of total billed charges,80% of total billed charges,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.94 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.21 ,$35.12 ,
SALEM SUMP TUBE 8 FR,12405,CDM,270,RC,,HCPCS,outpatient,,,$36.97 ,$12.94 ,,$19.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$27.73 ,75,,,percent of total billed charges,75% of total billed charges,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,80,,,percent of total billed charges,80% of total billed charges,$11.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.94 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.21 ,$35.12 ,
SALINE 9% 5ML ADDIPAK STERILE,30040,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
SCALPEL DISP # 15  371615,30060,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
SCALPEL DISP #10,30058,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SCISSOR TIP CURVED METZ,12626,CDM,270,RC,,HCPCS,outpatient,,,$273.97 ,$95.89 ,,$146.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$146.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$205.48 ,75,,,percent of total billed charges,75% of total billed charges,$205.48 ,75,,,percent of total billed charges,75% of total billed charges,$205.48 ,75,,,percent of total billed charges,75% of total billed charges,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.18 ,80,,,percent of total billed charges,80% of total billed charges,$86.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$95.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$191.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$210.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$84.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$246.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$260.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$205.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$205.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$205.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$232.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.42 ,$260.27 ,
SCOTCH CAST SPLINT 4 X 15,12478,CDM,270,RC,,HCPCS,outpatient,,,$27.64 ,$9.67 ,,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.39 ,$26.26 ,
SCOTCH CAST SPLINT 4 X 30,12479,CDM,270,RC,,HCPCS,outpatient,,,$27.64 ,$9.67 ,,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.39 ,$26.26 ,
SCOTCH CAST SPLINT 5 X 30,12480,CDM,270,RC,,HCPCS,outpatient,,,$27.64 ,$9.67 ,,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.39 ,$26.26 ,
SCOTCH CAST SPLINT 3 X 35,12482,CDM,270,RC,,HCPCS,outpatient,,,$27.64 ,$9.67 ,,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.39 ,$26.26 ,
SCOTCH CAST SPLINT2 X 10,12483,CDM,270,RC,,HCPCS,outpatient,,,$27.64 ,$9.67 ,,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$20.73 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges,$8.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.39 ,$26.26 ,
SCOTCH CAST SPLINT 3 X12,12481,CDM,270,RC,,HCPCS,outpatient,,,$26.57 ,$9.30 ,,$14.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.93 ,75,,,percent of total billed charges,75% of total billed charges,$19.93 ,75,,,percent of total billed charges,75% of total billed charges,$19.93 ,75,,,percent of total billed charges,75% of total billed charges,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.26 ,80,,,percent of total billed charges,80% of total billed charges,$8.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.18 ,$25.24 ,
"SEAL EAKIN COHESIVE LARGE 4""",30085,CDM,270,RC,,HCPCS,outpatient,,,$15.03 ,$5.26 ,,$8.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.27 ,75,,,percent of total billed charges,75% of total billed charges,$11.27 ,75,,,percent of total billed charges,75% of total billed charges,$11.27 ,75,,,percent of total billed charges,75% of total billed charges,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,80,,,percent of total billed charges,80% of total billed charges,$4.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.93 ,$14.28 ,
SECONDARY MED. SET,11600,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SHAVE AND PREP KIT,12170,CDM,272,RC,,HCPCS,outpatient,,,$23.39 ,$8.19 ,,$12.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.54 ,75,,,percent of total billed charges,75% of total billed charges,$17.54 ,75,,,percent of total billed charges,75% of total billed charges,$17.54 ,75,,,percent of total billed charges,75% of total billed charges,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,80,,,percent of total billed charges,80% of total billed charges,$7.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.37 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.56 ,$22.22 ,
SHILEY TRACH CANNULA 6DFEN,28714,CDM,270,RC,,HCPCS,outpatient,,,$43.12 ,$15.09 ,,$23.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.34 ,75,,,percent of total billed charges,75% of total billed charges,$32.34 ,75,,,percent of total billed charges,75% of total billed charges,$32.34 ,75,,,percent of total billed charges,75% of total billed charges,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.50 ,80,,,percent of total billed charges,80% of total billed charges,$13.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.09 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.34 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.41 ,$40.96 ,
SIGMOID SUCTION INSTRUMENT,11114,CDM,270,RC,,HCPCS,outpatient,,,$332.44 ,$116.35 ,,$178.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$178.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$249.33 ,75,,,percent of total billed charges,75% of total billed charges,$249.33 ,75,,,percent of total billed charges,75% of total billed charges,$249.33 ,75,,,percent of total billed charges,75% of total billed charges,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$265.95 ,80,,,percent of total billed charges,80% of total billed charges,$105.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$265.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$232.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$232.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$255.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$103.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$299.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$315.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$249.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$249.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$249.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$282.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.83 ,$315.82 ,
SILICONE FLAT DRAIN 7 MM,12566,CDM,270,RC,,HCPCS,outpatient,,,$37.12 ,$12.99 ,,$19.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,80,,,percent of total billed charges,80% of total billed charges,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.24 ,$35.26 ,
SILICONE FLAT DRAIN 10 MM,12804,CDM,270,RC,,HCPCS,outpatient,,,$37.12 ,$12.99 ,,$19.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$27.84 ,75,,,percent of total billed charges,75% of total billed charges,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.70 ,80,,,percent of total billed charges,80% of total billed charges,$11.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.98 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.24 ,$35.26 ,
SITZ BATH,11115,CDM,270,RC,,HCPCS,outpatient,,,$26.84 ,$9.39 ,,$14.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.13 ,75,,,percent of total billed charges,75% of total billed charges,$20.13 ,75,,,percent of total billed charges,75% of total billed charges,$20.13 ,75,,,percent of total billed charges,75% of total billed charges,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.47 ,80,,,percent of total billed charges,80% of total billed charges,$8.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.96 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.23 ,$25.50 ,
SKIN BARRIER W / FLANGE,11265,CDM,274,RC,,HCPCS,outpatient,,,$24.30 ,$8.51 ,,$13.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.23 ,75,,,percent of total billed charges,75% of total billed charges,$18.23 ,75,,,percent of total billed charges,75% of total billed charges,$18.23 ,75,,,percent of total billed charges,75% of total billed charges,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.44 ,80,,,percent of total billed charges,80% of total billed charges,$7.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.44 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.74 ,$23.09 ,
SKINTEGRITY HYDROGEL 4 OZ,30041,CDM,270,RC,,HCPCS,outpatient,,,$21.98 ,$7.69 ,,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$16.49 ,75,,,percent of total billed charges,75% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges,$6.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.69 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.49 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.37 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.29 ,$20.88 ,
SLING & SWATHE UNIVERSAL (LARGER SIZE),11415,CDM,274,RC,,HCPCS,outpatient,,,$64.52 ,$22.58 ,,$34.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.39 ,75,,,percent of total billed charges,75% of total billed charges,$48.39 ,75,,,percent of total billed charges,75% of total billed charges,$48.39 ,75,,,percent of total billed charges,75% of total billed charges,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.62 ,80,,,percent of total billed charges,80% of total billed charges,$20.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.58 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$58.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.29 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.58 ,$61.29 ,
SLING & SWATHE UNIVERSAL S/M,12730,CDM,270,RC,,HCPCS,outpatient,,,$61.53 ,$21.54 ,,$32.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.15 ,75,,,percent of total billed charges,75% of total billed charges,$46.15 ,75,,,percent of total billed charges,75% of total billed charges,$46.15 ,75,,,percent of total billed charges,75% of total billed charges,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,80,,,percent of total billed charges,80% of total billed charges,$19.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.54 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.00 ,$58.45 ,
SNARE ELECTROSURGICAL DISP  SD-210U-25,11896,CDM,270,RC,,HCPCS,outpatient,,,$80.73 ,$28.26 ,,$43.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.55 ,75,,,percent of total billed charges,75% of total billed charges,$60.55 ,75,,,percent of total billed charges,75% of total billed charges,$60.55 ,75,,,percent of total billed charges,75% of total billed charges,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.58 ,80,,,percent of total billed charges,80% of total billed charges,$25.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$72.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.69 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$60.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.74 ,$76.69 ,
SNARE ELECTROSURGICAL DISP  SD-240U-15,12529,CDM,270,RC,,HCPCS,outpatient,,,$59.98 ,$20.99 ,,$32.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.99 ,75,,,percent of total billed charges,75% of total billed charges,$44.99 ,75,,,percent of total billed charges,75% of total billed charges,$44.99 ,75,,,percent of total billed charges,75% of total billed charges,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.98 ,80,,,percent of total billed charges,80% of total billed charges,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.99 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.70 ,$56.98 ,
SOLIDIFIER FOR SUCT. CAN.,12365,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SOLUTION PREP PROVIDINE IODINE 8 OZ  MDS093943,30036,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPECULA VAGINAL ILL SMALL,12731,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPECULA VAGINAL ILL MEDIUM,13666,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPECULUM VAGINAL LG  DISPOSABLE,30082,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPINAL ANESTHESIA TRAY,11118,CDM,270,RC,,HCPCS,outpatient,,,$102.79 ,$35.98 ,,$55.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.09 ,75,,,percent of total billed charges,75% of total billed charges,$77.09 ,75,,,percent of total billed charges,75% of total billed charges,$77.09 ,75,,,percent of total billed charges,75% of total billed charges,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.23 ,80,,,percent of total billed charges,80% of total billed charges,$32.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$92.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$77.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.37 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.04 ,$97.65 ,
SPINAL NEEDLE 18 GA X 3.50,28872,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPINAL NEEDLE 22 GA X 1 1/2,11907,CDM,270,RC,,HCPCS,outpatient,,,$26.90 ,$9.42 ,,$14.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.18 ,75,,,percent of total billed charges,75% of total billed charges,$20.18 ,75,,,percent of total billed charges,75% of total billed charges,$20.18 ,75,,,percent of total billed charges,75% of total billed charges,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.52 ,80,,,percent of total billed charges,80% of total billed charges,$8.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$24.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.56 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$20.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.25 ,$25.56 ,
"SPINAL NEEDLE 22ga X 5""",28620,CDM,270,RC,,HCPCS,outpatient,,,$54.63 ,$19.12 ,,$29.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.97 ,75,,,percent of total billed charges,75% of total billed charges,$40.97 ,75,,,percent of total billed charges,75% of total billed charges,$40.97 ,75,,,percent of total billed charges,75% of total billed charges,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.70 ,80,,,percent of total billed charges,80% of total billed charges,$17.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.65 ,$51.90 ,
SPLINT COCKUP LOOP LOCK FASTEN LH LG,11706,CDM,274,RC,,HCPCS,outpatient,,,$22.89 ,$8.01 ,,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.46 ,$21.75 ,
SPLINT COCKUP LOOP LOCK FASTEN RH LG,12734,CDM,270,RC,,HCPCS,outpatient,,,$22.89 ,$8.01 ,,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.46 ,$21.75 ,
SPLINT COCKUP LOOP LOCK FASTEN RH MD,12735,CDM,270,RC,,HCPCS,outpatient,,,$35.28 ,$12.35 ,,$18.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.46 ,75,,,percent of total billed charges,75% of total billed charges,$26.46 ,75,,,percent of total billed charges,75% of total billed charges,$26.46 ,75,,,percent of total billed charges,75% of total billed charges,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.22 ,80,,,percent of total billed charges,80% of total billed charges,$11.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.52 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.88 ,$33.52 ,
SPLINT COCKUP LOOP LOCK FASTEN LH MD,12732,CDM,270,RC,,HCPCS,outpatient,,,$47.00 ,$16.45 ,,$25.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.60 ,80,,,percent of total billed charges,80% of total billed charges,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.17 ,$44.65 ,
SPLINT COCKUP LOOP LOCK FASTEN LH SM,12733,CDM,272,RC,,HCPCS,outpatient,,,$58.28 ,$20.40 ,,$31.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.71 ,75,,,percent of total billed charges,75% of total billed charges,$43.71 ,75,,,percent of total billed charges,75% of total billed charges,$43.71 ,75,,,percent of total billed charges,75% of total billed charges,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.62 ,80,,,percent of total billed charges,80% of total billed charges,$18.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.36 ,$55.37 ,
SPLINT COCKUP LOOP LOCK FASTEN RH SM,12736,CDM,272,RC,,HCPCS,outpatient,,,$66.73 ,$23.36 ,,$35.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.05 ,75,,,percent of total billed charges,75% of total billed charges,$50.05 ,75,,,percent of total billed charges,75% of total billed charges,$50.05 ,75,,,percent of total billed charges,75% of total billed charges,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.38 ,80,,,percent of total billed charges,80% of total billed charges,$21.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.06 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.01 ,$63.39 ,
SPLINT FIBERGLASS FOOT,30088,CDM,270,RC,,HCPCS,outpatient,,,$310.72 ,$108.75 ,,$166.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$166.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.04 ,75,,,percent of total billed charges,75% of total billed charges,$233.04 ,75,,,percent of total billed charges,75% of total billed charges,$233.04 ,75,,,percent of total billed charges,75% of total billed charges,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.58 ,80,,,percent of total billed charges,80% of total billed charges,$98.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$108.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$248.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$217.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$239.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$97.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$97.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$96.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$279.65 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$62.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$295.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$233.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$233.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$233.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$62.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$264.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.59 ,$295.18 ,
SPLINT FINGER ALUM,11121,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SPLINT FINGER PD 6,12737,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
"SPLINT HAND, MASON ALLEN SM",11743,CDM,270,RC,,HCPCS,outpatient,,,$45.31 ,$15.86 ,,$24.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.98 ,75,,,percent of total billed charges,75% of total billed charges,$33.98 ,75,,,percent of total billed charges,75% of total billed charges,$33.98 ,75,,,percent of total billed charges,75% of total billed charges,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.25 ,80,,,percent of total billed charges,80% of total billed charges,$14.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.14 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.84 ,$43.04 ,
"SPLINT HAND, MASON ALLEN LG",12738,CDM,270,RC,,HCPCS,outpatient,,,$78.00 ,$27.30 ,,$41.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.50 ,75,,,percent of total billed charges,75% of total billed charges,$58.50 ,75,,,percent of total billed charges,75% of total billed charges,$58.50 ,75,,,percent of total billed charges,75% of total billed charges,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.40 ,80,,,percent of total billed charges,80% of total billed charges,$24.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$27.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$62.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$70.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$66.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.21 ,$74.10 ,
SPLINT PLASTER UNIVERSAL 4 OCL,12739,CDM,270,RC,,HCPCS,outpatient,,,$176.00 ,$61.60 ,,$94.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.00 ,75,,,percent of total billed charges,75% of total billed charges,$132.00 ,75,,,percent of total billed charges,75% of total billed charges,$132.00 ,75,,,percent of total billed charges,75% of total billed charges,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.80 ,80,,,percent of total billed charges,80% of total billed charges,$55.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$135.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.56 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$158.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$167.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$132.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$132.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$132.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$149.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.32 ,$167.20 ,
SPLINT SPEC PL 3 OCL,12741,CDM,270,RC,,HCPCS,outpatient,,,$211.00 ,$73.85 ,,$113.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$158.25 ,75,,,percent of total billed charges,75% of total billed charges,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$168.80 ,80,,,percent of total billed charges,80% of total billed charges,$66.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$73.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$147.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$162.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$66.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$65.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$189.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$200.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$158.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$179.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.15 ,$200.45 ,
SPLINT T/F LARGE,11194,CDM,270,RC,,HCPCS,outpatient,,,$275.00 ,$96.25 ,,$147.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$147.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$206.25 ,75,,,percent of total billed charges,75% of total billed charges,$206.25 ,75,,,percent of total billed charges,75% of total billed charges,$206.25 ,75,,,percent of total billed charges,75% of total billed charges,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.00 ,80,,,percent of total billed charges,80% of total billed charges,$86.96 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$96.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$220.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$192.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$211.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$85.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$247.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$55.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$261.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$54.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$206.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$206.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$206.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$233.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.70 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.63 ,$261.25 ,
SPLINT T/F MEDIUM,11198,CDM,270,RC,,HCPCS,outpatient,,,$151.00 ,$52.85 ,,$80.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.94 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$113.25 ,75,,,percent of total billed charges,75% of total billed charges,$113.25 ,75,,,percent of total billed charges,75% of total billed charges,$113.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.80 ,80,,,percent of total billed charges,80% of total billed charges,$47.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$143.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$113.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$113.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$128.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.45 ,$143.45 ,
SPLINT T/F SMALL PADDED,12775,CDM,270,RC,,HCPCS,outpatient,,,$106.89 ,$37.41 ,,$57.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.17 ,75,,,percent of total billed charges,75% of total billed charges,$80.17 ,75,,,percent of total billed charges,75% of total billed charges,$80.17 ,75,,,percent of total billed charges,75% of total billed charges,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.51 ,80,,,percent of total billed charges,80% of total billed charges,$33.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.41 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.47 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$96.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$101.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$80.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$80.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.84 ,$101.55 ,
SPLINT WRIST COMFORFOAM RH XL,12745,CDM,270,RC,,HCPCS,outpatient,,,$55.00 ,$19.25 ,,$29.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.00 ,80,,,percent of total billed charges,80% of total billed charges,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.73 ,$52.25 ,
SPLINT WRIST FOAM LT SM,12506,CDM,270,RC,,HCPCS,outpatient,,,$40.00 ,$14.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.80 ,$38.00 ,
SPLINT WRIST FOAM RH MED,12743,CDM,270,RC,,HCPCS,outpatient,,,$46.00 ,$16.10 ,,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.50 ,75,,,percent of total billed charges,75% of total billed charges,$34.50 ,75,,,percent of total billed charges,75% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.80 ,80,,,percent of total billed charges,80% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.78 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.97 ,$43.70 ,
SPLINT WRIST FOAM RH SM,12744,CDM,270,RC,,HCPCS,outpatient,,,$38.00 ,$13.30 ,,$20.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.50 ,75,,,percent of total billed charges,75% of total billed charges,$28.50 ,75,,,percent of total billed charges,75% of total billed charges,$28.50 ,75,,,percent of total billed charges,75% of total billed charges,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.40 ,80,,,percent of total billed charges,80% of total billed charges,$12.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.41 ,$36.10 ,
SPLINT WRIST FOAM LH LG,11122,CDM,270,RC,,HCPCS,outpatient,,,$45.00 ,$15.75 ,,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$33.75 ,75,,,percent of total billed charges,75% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges,$14.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,$42.75 ,
SPLINT WRIST FOAM RH LG,12742,CDM,270,RC,,HCPCS,outpatient,,,$40.00 ,$14.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.80 ,$38.00 ,
SPLINT WRIST FOAM LT MED,11707,CDM,270,RC,,HCPCS,outpatient,,,$47.00 ,$16.45 ,,$25.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$35.25 ,75,,,percent of total billed charges,75% of total billed charges,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.60 ,80,,,percent of total billed charges,80% of total billed charges,$14.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.17 ,$44.65 ,
SPLINT WRIST UNIVERSAL,93074,CDM,272,RC,,HCPCS,outpatient,,,$13.81 ,$4.83 ,,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$10.36 ,75,,,percent of total billed charges,75% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges,$4.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.69 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.77 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.69 ,$13.12 ,
SPLINT WRIST XL,28570,CDM,270,RC,,HCPCS,outpatient,,,$40.00 ,$14.00 ,,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$30.00 ,75,,,percent of total billed charges,75% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges,$12.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$36.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.80 ,$38.00 ,
SPONGE KITTNER DISS,12815,CDM,270,RC,,HCPCS,outpatient,,,$14.31 ,$5.01 ,,$7.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$10.73 ,75,,,percent of total billed charges,75% of total billed charges,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.45 ,80,,,percent of total billed charges,80% of total billed charges,$4.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.85 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.79 ,$13.59 ,
SPRING GRIP N/C 5MM-10MM ANCHORING,12751,CDM,270,RC,,HCPCS,outpatient,,,$61.27 ,$21.44 ,,$32.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.95 ,75,,,percent of total billed charges,75% of total billed charges,$45.95 ,75,,,percent of total billed charges,75% of total billed charges,$45.95 ,75,,,percent of total billed charges,75% of total billed charges,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.02 ,80,,,percent of total billed charges,80% of total billed charges,$19.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.89 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.89 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.08 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.95 ,$58.21 ,
SPRING GRIP N/C 5MM ANCHORING DEVICE,11754,CDM,270,RC,,HCPCS,outpatient,,,$64.99 ,$22.75 ,,$34.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.74 ,75,,,percent of total billed charges,75% of total billed charges,$48.74 ,75,,,percent of total billed charges,75% of total billed charges,$48.74 ,75,,,percent of total billed charges,75% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.99 ,80,,,percent of total billed charges,80% of total billed charges,$20.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$58.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$48.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.67 ,$61.74 ,
SPRING WIRE GUIDE,11549,CDM,270,RC,,HCPCS,outpatient,,,$192.38 ,$67.33 ,,$103.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$144.29 ,75,,,percent of total billed charges,75% of total billed charges,$144.29 ,75,,,percent of total billed charges,75% of total billed charges,$144.29 ,75,,,percent of total billed charges,75% of total billed charges,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$153.90 ,80,,,percent of total billed charges,80% of total billed charges,$60.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$67.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$153.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$148.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$60.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$59.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$173.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$38.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$182.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$144.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$144.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$163.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.51 ,$182.76 ,
STAPLE EXTRACTOR,11132,CDM,270,RC,,HCPCS,outpatient,,,$19.54 ,$6.84 ,,$10.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.47 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.66 ,75,,,percent of total billed charges,75% of total billed charges,$14.66 ,75,,,percent of total billed charges,75% of total billed charges,$14.66 ,75,,,percent of total billed charges,75% of total billed charges,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.63 ,80,,,percent of total billed charges,80% of total billed charges,$6.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.56 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.81 ,$18.56 ,
STAPLER M/F GIA 60-3.8,11572,CDM,270,RC,,HCPCS,outpatient,,,$433.16 ,$151.61 ,,$232.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$232.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$324.87 ,75,,,percent of total billed charges,75% of total billed charges,$324.87 ,75,,,percent of total billed charges,75% of total billed charges,$324.87 ,75,,,percent of total billed charges,75% of total billed charges,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$346.53 ,80,,,percent of total billed charges,80% of total billed charges,$136.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$151.61 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$303.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$333.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$389.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$86.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$411.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$324.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$324.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$324.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$86.98 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$368.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.47 ,$411.50 ,
STAPLER M/F TA 60-3.5 DISP,11656,CDM,270,RC,,HCPCS,outpatient,,,$412.04 ,$144.21 ,,$220.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$220.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$309.03 ,75,,,percent of total billed charges,75% of total billed charges,$309.03 ,75,,,percent of total billed charges,75% of total billed charges,$309.03 ,75,,,percent of total billed charges,75% of total billed charges,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$329.63 ,80,,,percent of total billed charges,80% of total billed charges,$130.29 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$144.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$329.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$288.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$317.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$129.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$127.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$370.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$82.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$391.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$329.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$383.20 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$309.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$309.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$350.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.35 ,$391.44 ,
STAPLER M/F TA 90-3.5,11369,CDM,270,RC,,HCPCS,outpatient,,,"$1,286.21 ",$450.17 ,,$689.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$689.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$964.66 ,75,,,percent of total billed charges,75% of total billed charges,$964.66 ,75,,,percent of total billed charges,75% of total billed charges,$964.66 ,75,,,percent of total billed charges,75% of total billed charges,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,028.97 ",80,,,percent of total billed charges,80% of total billed charges,$406.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$450.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,028.97 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$900.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$900.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$990.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$402.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$402.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$398.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,157.59 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$258.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,221.90 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,028.97 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$255.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,196.18 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$964.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$964.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$964.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$258.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,093.28 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.81 ,"$1,221.90 ",
STAPLER PRECISE D-35,12747,CDM,270,RC,,HCPCS,outpatient,,,$51.58 ,$18.05 ,,$27.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.69 ,75,,,percent of total billed charges,75% of total billed charges,$38.69 ,75,,,percent of total billed charges,75% of total billed charges,$38.69 ,75,,,percent of total billed charges,75% of total billed charges,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.26 ,80,,,percent of total billed charges,80% of total billed charges,$16.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.72 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.97 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$38.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.06 ,$49.00 ,
STAPLER PRECISE DS-15,11400,CDM,270,RC,,HCPCS,outpatient,,,$30.18 ,$10.56 ,,$16.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.64 ,75,,,percent of total billed charges,75% of total billed charges,$22.64 ,75,,,percent of total billed charges,75% of total billed charges,$22.64 ,75,,,percent of total billed charges,75% of total billed charges,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.14 ,80,,,percent of total billed charges,80% of total billed charges,$9.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.89 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$27.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.89 ,$28.67 ,
STAPLER PRECISE DS25,11761,CDM,270,RC,,HCPCS,outpatient,,,$30.62 ,$10.72 ,,$16.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.97 ,75,,,percent of total billed charges,75% of total billed charges,$22.97 ,75,,,percent of total billed charges,75% of total billed charges,$22.97 ,75,,,percent of total billed charges,75% of total billed charges,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.50 ,80,,,percent of total billed charges,80% of total billed charges,$9.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$27.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.50 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.97 ,$29.09 ,
STAPLER PREM DISP EEA31,12752,CDM,270,RC,,HCPCS,outpatient,,,"$1,207.74 ",$422.71 ,,$647.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$647.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$905.81 ,75,,,percent of total billed charges,75% of total billed charges,$905.81 ,75,,,percent of total billed charges,75% of total billed charges,$905.81 ,75,,,percent of total billed charges,75% of total billed charges,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$966.19 ,80,,,percent of total billed charges,80% of total billed charges,$381.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$422.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$966.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$845.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$845.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$929.96 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$374.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,086.97 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$242.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,147.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$966.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$240.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,123.20 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$905.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$905.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$905.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$242.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,026.58 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$235.51 ,"$1,147.35 ",
STAPLER PREMIUM EEA 33MM,30245,CDM,272,RC,,HCPCS,outpatient,,,"$1,457.61 ",$510.16 ,,$781.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$781.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,166.09 ",80,,,percent of total billed charges,80% of total billed charges,$460.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$510.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,166.09 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.33 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,020.33 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,122.36 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$456.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$451.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,311.85 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$292.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,384.73 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,166.09 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$289.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,093.21 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$292.69 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,238.97 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$284.23 ,"$1,384.73 ",
STAPLER PROXIMATE SKIN,11116,CDM,270,RC,,HCPCS,outpatient,,,$159.48 ,$55.82 ,,$85.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.61 ,75,,,percent of total billed charges,75% of total billed charges,$119.61 ,75,,,percent of total billed charges,75% of total billed charges,$119.61 ,75,,,percent of total billed charges,75% of total billed charges,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.58 ,80,,,percent of total billed charges,80% of total billed charges,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.64 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.44 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.10 ,$151.51 ,
STAPLER SKIN PROXIMATE PXW35,20260,CDM,270,RC,,HCPCS,outpatient,,,$177.48 ,$62.12 ,,$95.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$95.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$133.11 ,75,,,percent of total billed charges,75% of total billed charges,$133.11 ,75,,,percent of total billed charges,75% of total billed charges,$133.11 ,75,,,percent of total billed charges,75% of total billed charges,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$141.98 ,80,,,percent of total billed charges,80% of total billed charges,$56.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$62.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$124.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$136.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$55.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$159.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$168.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$133.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$133.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.64 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$150.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.61 ,$168.61 ,
STAPLER SKIN PROXOMATE PRW35,93053,CDM,272,RC,,HCPCS,outpatient,,,$300.10 ,$105.04 ,,$160.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$160.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.08 ,75,,,percent of total billed charges,75% of total billed charges,$225.08 ,75,,,percent of total billed charges,75% of total billed charges,$225.08 ,75,,,percent of total billed charges,75% of total billed charges,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.08 ,80,,,percent of total billed charges,80% of total billed charges,$94.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$105.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$210.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$231.08 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$93.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$270.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$225.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$225.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$225.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$255.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.52 ,$285.10 ,
START KIT W/ DIRECTIONAL TIP & CLEAR T PIECE,11770,CDM,270,RC,,HCPCS,outpatient,,,$60.49 ,$21.17 ,,$32.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.37 ,75,,,percent of total billed charges,75% of total billed charges,$45.37 ,75,,,percent of total billed charges,75% of total billed charges,$45.37 ,75,,,percent of total billed charges,75% of total billed charges,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.39 ,80,,,percent of total billed charges,80% of total billed charges,$19.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.80 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.39 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.80 ,$57.47 ,
STERI STRIP 1/2 X 4,11128,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
STERI STRIP 1/4 X 3,11129,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STERI STRIP 1/4 X 1 1/2 (R1542),11130,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STERILE GAUZE FLUFF ROLL,30039,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STOCKINETTE 3,12372,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STOCKINETTE 4,12373,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STOCKINETTE 6,12374,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STOCKINETTE IMPERVIOUS MED,11316,CDM,270,RC,,HCPCS,outpatient,,,$35.53 ,$12.44 ,,$19.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.65 ,75,,,percent of total billed charges,75% of total billed charges,$26.65 ,75,,,percent of total billed charges,75% of total billed charges,$26.65 ,75,,,percent of total billed charges,75% of total billed charges,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,80,,,percent of total billed charges,80% of total billed charges,$11.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.93 ,$33.75 ,
STOCKING  THIGH HI LARGE REG,12360,CDM,270,RC,,HCPCS,outpatient,,,$37.44 ,$13.10 ,,$20.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.08 ,75,,,percent of total billed charges,75% of total billed charges,$28.08 ,75,,,percent of total billed charges,75% of total billed charges,$28.08 ,75,,,percent of total billed charges,75% of total billed charges,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.95 ,80,,,percent of total billed charges,80% of total billed charges,$11.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.82 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.30 ,$35.57 ,
STOPCOCK 3 WAY MALE,11248,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STRUCTURAL BALLOON TROCAR,12892,CDM,270,RC,,HCPCS,outpatient,,,$905.06 ,$316.77 ,,$485.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$485.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$678.80 ,75,,,percent of total billed charges,75% of total billed charges,$678.80 ,75,,,percent of total billed charges,75% of total billed charges,$678.80 ,75,,,percent of total billed charges,75% of total billed charges,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$724.05 ,80,,,percent of total billed charges,80% of total billed charges,$286.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$316.77 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$724.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$633.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$633.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$696.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$283.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$283.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$283.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$283.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$283.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.49 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$280.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$814.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$181.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$859.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$724.05 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$180.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$841.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$678.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$678.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$678.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$181.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$769.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$180.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$176.49 ,$859.81 ,
STYLET 14 FR,12183,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
STYLET NEONATAL 6 FR,12182,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCT. CATH W / G & B 14 FR,11137,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCTION / IRRIGATION HANDPIECE,12897,CDM,270,RC,,HCPCS,outpatient,,,$181.20 ,$63.42 ,,$97.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$135.90 ,75,,,percent of total billed charges,75% of total billed charges,$135.90 ,75,,,percent of total billed charges,75% of total billed charges,$135.90 ,75,,,percent of total billed charges,75% of total billed charges,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$144.96 ,80,,,percent of total billed charges,80% of total billed charges,$57.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$126.84 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$163.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$172.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$135.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$135.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.33 ,$172.14 ,
SUCTION CANISTER 1200 CC,11138,CDM,270,RC,,HCPCS,outpatient,,,$24.72 ,$8.65 ,,$13.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.54 ,75,,,percent of total billed charges,75% of total billed charges,$18.54 ,75,,,percent of total billed charges,75% of total billed charges,$18.54 ,75,,,percent of total billed charges,75% of total billed charges,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.78 ,80,,,percent of total billed charges,80% of total billed charges,$7.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.48 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.82 ,$23.48 ,
SUCTION CANISTER 2000 CC,12820,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCTION CANISTER FILTER MEDLEA,28876,CDM,270,RC,,HCPCS,outpatient,,,$55.13 ,$19.30 ,,$29.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.35 ,75,,,percent of total billed charges,75% of total billed charges,$41.35 ,75,,,percent of total billed charges,75% of total billed charges,$41.35 ,75,,,percent of total billed charges,75% of total billed charges,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.10 ,80,,,percent of total billed charges,80% of total billed charges,$17.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.62 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.86 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.97 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.75 ,$52.37 ,
SUCTION CANISTER LINER MEDELA 1500,28874,CDM,270,RC,,HCPCS,outpatient,,,$15.60 ,$5.46 ,,$8.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.70 ,75,,,percent of total billed charges,75% of total billed charges,$11.70 ,75,,,percent of total billed charges,75% of total billed charges,$11.70 ,75,,,percent of total billed charges,75% of total billed charges,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.48 ,80,,,percent of total billed charges,80% of total billed charges,$4.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.82 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.04 ,$14.82 ,
SUCTION CANISTER TUBING,28875,CDM,270,RC,,HCPCS,outpatient,,,$22.05 ,$7.72 ,,$11.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$16.54 ,75,,,percent of total billed charges,75% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.64 ,80,,,percent of total billed charges,80% of total billed charges,$6.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.30 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.43 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.30 ,$20.95 ,
"SUCTION COAG 6"" 10 FR W/ HAND SWITCH",93106,CDM,272,RC,,HCPCS,outpatient,,,$57.65 ,$20.18 ,,$30.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.24 ,75,,,percent of total billed charges,75% of total billed charges,$43.24 ,75,,,percent of total billed charges,75% of total billed charges,$43.24 ,75,,,percent of total billed charges,75% of total billed charges,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.12 ,80,,,percent of total billed charges,80% of total billed charges,$18.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.89 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.24 ,$54.77 ,
SUCTION CONNECTING TUBE 6',11158,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCTION TIP FRAZIER 8FR,11304,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCTION TIP POOLE,11352,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUCTION TUBE ATTACHMENT DEVICE,11645,CDM,270,RC,,HCPCS,outpatient,,,$11.65 ,$4.08 ,,$6.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.74 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,75,,,percent of total billed charges,75% of total billed charges,$8.74 ,75,,,percent of total billed charges,75% of total billed charges,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.32 ,80,,,percent of total billed charges,80% of total billed charges,$3.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.65 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.07 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.27 ,$11.07 ,
SUREPREP RAPID DRY BARRIER FILM 1 ML,30049,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SURGICAL SHOE MENS MED BLUE,12715,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
SURGICAL SHOE MENS SMALL BLUE,12716,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
SURGICAL SHOE WOMENS LARGE BLUE,12717,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
SURGICAL SHOE WOMENS MED BLUE,12718,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
SURGICAL SHOE WOMENS SMALL BLUE,12719,CDM,270,RC,,HCPCS,outpatient,,,$15.75 ,$5.51 ,,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.44 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$11.81 ,75,,,percent of total billed charges,75% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges,$4.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.03 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.18 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.96 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.81 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.16 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.07 ,$14.96 ,
SURGICAL TROCAR & SYRINGE BLUNT TIP,11773,CDM,270,RC,,HCPCS,outpatient,,,$500.00 ,$175.00 ,,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$268.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$375.00 ,75,,,percent of total billed charges,75% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges,$158.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$175.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$350.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$385.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$97.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$155.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$450.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$475.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$400.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$375.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$425.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$97.50 ,$475.00 ,
SURGICEL 2 X 4 (1962),12536,CDM,270,RC,,HCPCS,outpatient,,,$785.09 ,$274.78 ,,$420.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$420.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$588.82 ,75,,,percent of total billed charges,75% of total billed charges,$588.82 ,75,,,percent of total billed charges,75% of total billed charges,$588.82 ,75,,,percent of total billed charges,75% of total billed charges,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$628.07 ,80,,,percent of total billed charges,80% of total billed charges,$248.25 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$274.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$628.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$549.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$549.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$604.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$153.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$243.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$706.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$157.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$745.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$628.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$156.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$730.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$588.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$588.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$588.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$157.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$667.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$153.09 ,$745.84 ,
SURGICLIP M-11.5 PREMIUM,11721,CDM,270,RC,,HCPCS,outpatient,,,$292.40 ,$102.34 ,,$156.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$156.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$219.30 ,75,,,percent of total billed charges,75% of total billed charges,$219.30 ,75,,,percent of total billed charges,75% of total billed charges,$219.30 ,75,,,percent of total billed charges,75% of total billed charges,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$233.92 ,80,,,percent of total billed charges,80% of total billed charges,$92.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$102.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$233.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$204.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$225.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$91.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$90.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$263.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.78 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$271.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$219.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$219.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$219.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$248.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.02 ,$277.78 ,
SURGIFOAM 2 X 6 CM 1972,93032,CDM,272,RC,,HCPCS,outpatient,,,$18.87 ,$6.60 ,,$10.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.15 ,75,,,percent of total billed charges,75% of total billed charges,$14.15 ,75,,,percent of total billed charges,75% of total billed charges,$14.15 ,75,,,percent of total billed charges,75% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.10 ,80,,,percent of total billed charges,80% of total billed charges,$5.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.79 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.68 ,$17.93 ,
SURGIFOAM ABSORBABLE GELATIN SPONGES,25484,CDM,272,RC,,HCPCS,outpatient,,,$171.66 ,$60.08 ,,$92.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$92.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$128.75 ,75,,,percent of total billed charges,75% of total billed charges,$128.75 ,75,,,percent of total billed charges,75% of total billed charges,$128.75 ,75,,,percent of total billed charges,75% of total billed charges,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.33 ,80,,,percent of total billed charges,80% of total billed charges,$54.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$60.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$120.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$132.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$53.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$53.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$154.49 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$163.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$128.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$128.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$128.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$145.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.47 ,$163.08 ,
SURGIFOAM SPONGE 8 cm x 6.25 cm x 1 cm (50cm),12705,CDM,270,RC,,HCPCS,outpatient,,,$184.42 ,$64.55 ,,$98.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$98.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$138.32 ,75,,,percent of total billed charges,75% of total billed charges,$138.32 ,75,,,percent of total billed charges,75% of total billed charges,$138.32 ,75,,,percent of total billed charges,75% of total billed charges,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$147.54 ,80,,,percent of total billed charges,80% of total billed charges,$58.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$142.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$165.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$175.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$171.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$138.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$138.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$138.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$156.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.96 ,$175.20 ,
SURGILAST SIZE 1 TUBULAR DRESSING,11642,CDM,270,RC,,HCPCS,outpatient,,,$39.58 ,$13.85 ,,$21.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.69 ,75,,,percent of total billed charges,75% of total billed charges,$29.69 ,75,,,percent of total billed charges,75% of total billed charges,$29.69 ,75,,,percent of total billed charges,75% of total billed charges,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.66 ,80,,,percent of total billed charges,80% of total billed charges,$12.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.48 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$35.62 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$29.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.72 ,$37.60 ,
SURGILAST SIZE 2 TUBULAR DRESSING,12725,CDM,270,RC,,HCPCS,outpatient,,,$31.13 ,$10.90 ,,$16.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.35 ,75,,,percent of total billed charges,75% of total billed charges,$23.35 ,75,,,percent of total billed charges,75% of total billed charges,$23.35 ,75,,,percent of total billed charges,75% of total billed charges,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.90 ,80,,,percent of total billed charges,80% of total billed charges,$9.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.35 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.07 ,$29.57 ,
SURGILAST SIZE 3 TUBULAR DRESSING,12726,CDM,270,RC,,HCPCS,outpatient,,,$54.76 ,$19.17 ,,$29.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.07 ,75,,,percent of total billed charges,75% of total billed charges,$41.07 ,75,,,percent of total billed charges,75% of total billed charges,$41.07 ,75,,,percent of total billed charges,75% of total billed charges,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.81 ,80,,,percent of total billed charges,80% of total billed charges,$17.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.28 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.68 ,$52.02 ,
SURGILAST SIZE 4 TUBULAR DRESSING,12749,CDM,270,RC,,HCPCS,outpatient,,,$43.24 ,$15.13 ,,$23.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.43 ,75,,,percent of total billed charges,75% of total billed charges,$32.43 ,75,,,percent of total billed charges,75% of total billed charges,$32.43 ,75,,,percent of total billed charges,75% of total billed charges,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.59 ,80,,,percent of total billed charges,80% of total billed charges,$13.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.40 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.59 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.43 ,$41.08 ,
SUSPENSORY LARGE,12186,CDM,272,RC,,HCPCS,outpatient,,,$52.18 ,$18.26 ,,$27.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.14 ,75,,,percent of total billed charges,75% of total billed charges,$39.14 ,75,,,percent of total billed charges,75% of total billed charges,$39.14 ,75,,,percent of total billed charges,75% of total billed charges,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.74 ,80,,,percent of total billed charges,80% of total billed charges,$16.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.96 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.57 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$39.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.18 ,$49.57 ,
SUSPENSORY X-LARGE,12187,CDM,272,RC,,HCPCS,outpatient,,,$46.15 ,$16.15 ,,$24.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.61 ,75,,,percent of total billed charges,75% of total billed charges,$34.61 ,75,,,percent of total billed charges,75% of total billed charges,$34.61 ,75,,,percent of total billed charges,75% of total billed charges,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.92 ,80,,,percent of total billed charges,80% of total billed charges,$14.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.00 ,$43.84 ,
SUTURE CHROMIC #1,11831,CDM,270,RC,,HCPCS,outpatient,,,$95.21 ,$33.32 ,,$51.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.17 ,80,,,percent of total billed charges,80% of total billed charges,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.57 ,$90.45 ,
SUTURE CHROMIC 0 884H,11456,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE CHROMIC 0812H,11452,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE CHROMIC 2-0 GUT  L113G,11737,CDM,270,RC,,HCPCS,outpatient,,,$99.41 ,$34.79 ,,$53.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.56 ,75,,,percent of total billed charges,75% of total billed charges,$74.56 ,75,,,percent of total billed charges,75% of total billed charges,$74.56 ,75,,,percent of total billed charges,75% of total billed charges,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.53 ,80,,,percent of total billed charges,80% of total billed charges,$31.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$89.47 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$74.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.56 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.38 ,$94.44 ,
SUTURE CHROMIC 2-0 GUT G123H,11461,CDM,270,RC,,HCPCS,outpatient,,,$85.21 ,$29.82 ,,$45.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.91 ,75,,,percent of total billed charges,75% of total billed charges,$63.91 ,75,,,percent of total billed charges,75% of total billed charges,$63.91 ,75,,,percent of total billed charges,75% of total billed charges,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.17 ,80,,,percent of total billed charges,80% of total billed charges,$26.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$59.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.42 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$76.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$63.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$72.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.62 ,$80.95 ,
SUTURE CHROMIC 3-0 (G122H),11457,CDM,270,RC,,HCPCS,outpatient,,,$39.20 ,$13.72 ,,$21.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.40 ,75,,,percent of total billed charges,75% of total billed charges,$29.40 ,75,,,percent of total billed charges,75% of total billed charges,$29.40 ,75,,,percent of total billed charges,75% of total billed charges,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.36 ,80,,,percent of total billed charges,80% of total billed charges,$12.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.27 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.15 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$35.28 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$29.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.64 ,$37.24 ,
SUTURE CHROMIC 4-0 (G121H),11677,CDM,270,RC,,HCPCS,outpatient,,,$21.29 ,$7.45 ,,$11.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.97 ,75,,,percent of total billed charges,75% of total billed charges,$15.97 ,75,,,percent of total billed charges,75% of total billed charges,$15.97 ,75,,,percent of total billed charges,75% of total billed charges,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.03 ,80,,,percent of total billed charges,80% of total billed charges,$6.73 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$19.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.15 ,$20.23 ,
SUTURE CHROMIC 5-0,11453,CDM,270,RC,,HCPCS,outpatient,,,$155.65 ,$54.48 ,,$83.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.74 ,75,,,percent of total billed charges,75% of total billed charges,$116.74 ,75,,,percent of total billed charges,75% of total billed charges,$116.74 ,75,,,percent of total billed charges,75% of total billed charges,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.52 ,80,,,percent of total billed charges,80% of total billed charges,$49.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$140.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$116.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.74 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.35 ,$147.87 ,
SUTURE CHROMIC 6-0,11173,CDM,270,RC,,HCPCS,outpatient,,,$162.60 ,$56.91 ,,$87.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.95 ,75,,,percent of total billed charges,75% of total billed charges,$121.95 ,75,,,percent of total billed charges,75% of total billed charges,$121.95 ,75,,,percent of total billed charges,75% of total billed charges,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.08 ,80,,,percent of total billed charges,80% of total billed charges,$51.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$121.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.71 ,$154.47 ,
SUTURE CHROMIC 813H,11673,CDM,270,RC,,HCPCS,outpatient,,,$89.89 ,$31.46 ,,$48.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.42 ,75,,,percent of total billed charges,75% of total billed charges,$67.42 ,75,,,percent of total billed charges,75% of total billed charges,$67.42 ,75,,,percent of total billed charges,75% of total billed charges,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.91 ,80,,,percent of total billed charges,80% of total billed charges,$28.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.15 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$85.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$67.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.53 ,$85.40 ,
SUTURE CHROMIC 925H,11460,CDM,270,RC,,HCPCS,outpatient,,,$95.21 ,$33.32 ,,$51.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$71.41 ,75,,,percent of total billed charges,75% of total billed charges,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.17 ,80,,,percent of total billed charges,80% of total billed charges,$30.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$85.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$80.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.57 ,$90.45 ,
SUTURE CHROMIC GUT 3-0 L112G,11451,CDM,270,RC,,HCPCS,outpatient,,,$96.36 ,$33.73 ,,$51.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.09 ,80,,,percent of total billed charges,80% of total billed charges,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.79 ,$91.54 ,
SUTURE CHROMIC GUT 3-0  636H,11890,CDM,270,RC,,HCPCS,outpatient,,,$81.86 ,$28.65 ,,$43.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.49 ,80,,,percent of total billed charges,80% of total billed charges,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$73.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.96 ,$77.77 ,
SUTURE CHROMIC GUT 2-0 811H,11449,CDM,270,RC,,HCPCS,outpatient,,,$84.00 ,$29.40 ,,$45.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.20 ,80,,,percent of total billed charges,80% of total billed charges,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$75.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.38 ,$79.80 ,
SUTURE CHROMIC GUT 2-0 883H,11455,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE CHROMIC GUT 4-0 (635H),11446,CDM,270,RC,,HCPCS,outpatient,,,$81.86 ,$28.65 ,,$43.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$61.40 ,75,,,percent of total billed charges,75% of total billed charges,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$65.49 ,80,,,percent of total billed charges,80% of total billed charges,$25.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.65 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$63.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$25.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$73.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$77.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.40 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$69.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.96 ,$77.77 ,
SUTURE CHROMIC GUT 2-0  903H,11695,CDM,270,RC,,HCPCS,outpatient,,,$95.88 ,$33.56 ,,$51.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.91 ,75,,,percent of total billed charges,75% of total billed charges,$71.91 ,75,,,percent of total billed charges,75% of total billed charges,$71.91 ,75,,,percent of total billed charges,75% of total billed charges,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.70 ,80,,,percent of total billed charges,80% of total billed charges,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.91 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.70 ,$91.09 ,
SUTURE CHROMIC GUT 3-0 922H,93011,CDM,272,RC,,HCPCS,outpatient,,,$12.54 ,$4.39 ,,$6.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.41 ,75,,,percent of total billed charges,75% of total billed charges,$9.41 ,75,,,percent of total billed charges,75% of total billed charges,$9.41 ,75,,,percent of total billed charges,75% of total billed charges,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.03 ,80,,,percent of total billed charges,80% of total billed charges,$3.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.39 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.52 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.66 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.45 ,$11.91 ,
SUTURE ETH X425H,12875,CDM,270,RC,,HCPCS,outpatient,,,$11.38 ,$3.98 ,,$6.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.54 ,75,,,percent of total billed charges,75% of total billed charges,$8.54 ,75,,,percent of total billed charges,75% of total billed charges,$8.54 ,75,,,percent of total billed charges,75% of total billed charges,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.10 ,80,,,percent of total billed charges,80% of total billed charges,$3.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.98 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.22 ,$10.81 ,
SUTURE ETHIBOND  0,11599,CDM,270,RC,,HCPCS,outpatient,,,$259.72 ,$90.90 ,,$139.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$194.79 ,75,,,percent of total billed charges,75% of total billed charges,$194.79 ,75,,,percent of total billed charges,75% of total billed charges,$194.79 ,75,,,percent of total billed charges,75% of total billed charges,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.78 ,80,,,percent of total billed charges,80% of total billed charges,$82.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$90.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$181.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$199.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$80.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$233.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$241.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$194.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$194.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$194.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.65 ,$246.73 ,
SUTURE ETHIBOND 0 EXCEL,11780,CDM,270,RC,,HCPCS,outpatient,,,$77.04 ,$26.96 ,,$41.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.78 ,75,,,percent of total billed charges,75% of total billed charges,$57.78 ,75,,,percent of total billed charges,75% of total billed charges,$57.78 ,75,,,percent of total billed charges,75% of total billed charges,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$61.63 ,80,,,percent of total billed charges,80% of total billed charges,$24.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$59.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$69.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.63 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$57.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$65.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.02 ,$73.19 ,
SUTURE ETHIBOND 1,93102,CDM,272,RC,,HCPCS,outpatient,,,$25.90 ,$9.07 ,,$13.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.43 ,75,,,percent of total billed charges,75% of total billed charges,$19.43 ,75,,,percent of total billed charges,75% of total billed charges,$19.43 ,75,,,percent of total billed charges,75% of total billed charges,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.72 ,80,,,percent of total billed charges,80% of total billed charges,$8.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.72 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.05 ,$24.61 ,
SUTURE ETHIBOND 2-0  X424H,11723,CDM,270,RC,,HCPCS,outpatient,,,$46.72 ,$16.35 ,,$25.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.04 ,75,,,percent of total billed charges,75% of total billed charges,$35.04 ,75,,,percent of total billed charges,75% of total billed charges,$35.04 ,75,,,percent of total billed charges,75% of total billed charges,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.38 ,80,,,percent of total billed charges,80% of total billed charges,$14.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.11 ,$44.38 ,
SUTURE ETHIBOND 2-0  X444H,11546,CDM,270,RC,,HCPCS,outpatient,,,$70.72 ,$24.75 ,,$37.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.04 ,75,,,percent of total billed charges,75% of total billed charges,$53.04 ,75,,,percent of total billed charges,75% of total billed charges,$53.04 ,75,,,percent of total billed charges,75% of total billed charges,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.58 ,80,,,percent of total billed charges,80% of total billed charges,$22.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.65 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.18 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.20 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.79 ,$67.18 ,
SUTURE ETHIBOND 2-0  MX553,11562,CDM,270,RC,,HCPCS,outpatient,,,$333.19 ,$116.62 ,,$178.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$178.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$249.89 ,75,,,percent of total billed charges,75% of total billed charges,$249.89 ,75,,,percent of total billed charges,75% of total billed charges,$249.89 ,75,,,percent of total billed charges,75% of total billed charges,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$266.55 ,80,,,percent of total billed charges,80% of total billed charges,$105.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$116.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$266.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$233.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$233.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$256.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.32 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$103.29 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$299.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$66.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$316.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$266.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$66.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$309.87 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$249.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$249.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$249.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$283.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.27 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$64.97 ,$316.53 ,
SUTURE ETHIBOND CX41D,12696,CDM,270,RC,,HCPCS,outpatient,,,$305.41 ,$106.89 ,,$163.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$163.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$229.06 ,75,,,percent of total billed charges,75% of total billed charges,$229.06 ,75,,,percent of total billed charges,75% of total billed charges,$229.06 ,75,,,percent of total billed charges,75% of total billed charges,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.33 ,80,,,percent of total billed charges,80% of total billed charges,$96.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$106.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$244.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$213.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$213.79 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$95.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$94.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$274.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$61.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$290.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$229.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$229.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$229.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$259.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.55 ,$290.14 ,
"SUTURE ETHIBOND GRN 2-0 18'"" CX12D",93013,CDM,272,RC,,HCPCS,outpatient,,,$41.37 ,$14.48 ,,$22.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.03 ,75,,,percent of total billed charges,75% of total billed charges,$31.03 ,75,,,percent of total billed charges,75% of total billed charges,$31.03 ,75,,,percent of total billed charges,75% of total billed charges,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.10 ,80,,,percent of total billed charges,80% of total billed charges,$13.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.07 ,$39.30 ,
SUTURE ETHIBOND MX69G,30151,CDM,270,RC,,HCPCS,outpatient,,,$106.15 ,$37.15 ,,$56.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.61 ,75,,,percent of total billed charges,75% of total billed charges,$79.61 ,75,,,percent of total billed charges,75% of total billed charges,$79.61 ,75,,,percent of total billed charges,75% of total billed charges,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.92 ,80,,,percent of total billed charges,80% of total billed charges,$33.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$95.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$100.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$79.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.23 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.70 ,$100.84 ,
SUTURE ETHIBOND X518H,12876,CDM,270,RC,,HCPCS,outpatient,,,$69.36 ,$24.28 ,,$37.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$52.02 ,75,,,percent of total billed charges,75% of total billed charges,$52.02 ,75,,,percent of total billed charges,75% of total billed charges,$52.02 ,75,,,percent of total billed charges,75% of total billed charges,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.49 ,80,,,percent of total billed charges,80% of total billed charges,$21.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$62.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$65.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$52.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.93 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.53 ,$65.89 ,
SUTURE ETHILON 1,11474,CDM,270,RC,,HCPCS,outpatient,,,$16.16 ,$5.66 ,,$8.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.12 ,75,,,percent of total billed charges,75% of total billed charges,$12.12 ,75,,,percent of total billed charges,75% of total billed charges,$12.12 ,75,,,percent of total billed charges,75% of total billed charges,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.93 ,80,,,percent of total billed charges,80% of total billed charges,$5.11 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$14.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$12.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.15 ,$15.35 ,
SUTURE ETHILON 1 (830H),11469,CDM,270,RC,,HCPCS,outpatient,,,$44.19 ,$15.47 ,,$23.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.14 ,75,,,percent of total billed charges,75% of total billed charges,$33.14 ,75,,,percent of total billed charges,75% of total billed charges,$33.14 ,75,,,percent of total billed charges,75% of total billed charges,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.35 ,80,,,percent of total billed charges,80% of total billed charges,$13.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.35 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.62 ,$41.98 ,
SUTURE ETHILON 2,11484,CDM,270,RC,,HCPCS,outpatient,,,$106.03 ,$37.11 ,,$56.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.52 ,75,,,percent of total billed charges,75% of total billed charges,$79.52 ,75,,,percent of total billed charges,75% of total billed charges,$79.52 ,75,,,percent of total billed charges,75% of total billed charges,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.82 ,80,,,percent of total billed charges,80% of total billed charges,$33.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$95.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$100.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$79.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.52 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.68 ,$100.73 ,
SUTURE ETHILON 2-0  1674H,11830,CDM,270,RC,,HCPCS,outpatient,,,$57.13 ,$20.00 ,,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.14 ,$54.27 ,
SUTURE ETHILON 2-0 628H,11477,CDM,270,RC,,HCPCS,outpatient,,,$57.13 ,$20.00 ,,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.14 ,$54.27 ,
SUTURE ETHILON 2-0 (664G),12433,CDM,270,RC,,HCPCS,outpatient,,,$55.19 ,$19.32 ,,$29.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.39 ,75,,,percent of total billed charges,75% of total billed charges,$41.39 ,75,,,percent of total billed charges,75% of total billed charges,$41.39 ,75,,,percent of total billed charges,75% of total billed charges,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.15 ,80,,,percent of total billed charges,80% of total billed charges,$17.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.32 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.15 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.63 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.15 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.76 ,$52.43 ,
SUTURE ETHILON 3-0  669H,12683,CDM,270,RC,,HCPCS,outpatient,,,$55.00 ,$19.25 ,,$29.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$41.25 ,75,,,percent of total billed charges,75% of total billed charges,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.00 ,80,,,percent of total billed charges,80% of total billed charges,$17.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$49.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$41.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.73 ,$52.25 ,
SUTURE ETHILON 3-0 663H,11478,CDM,270,RC,,HCPCS,outpatient,,,$56.35 ,$19.72 ,,$30.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.26 ,75,,,percent of total billed charges,75% of total billed charges,$42.26 ,75,,,percent of total billed charges,75% of total billed charges,$42.26 ,75,,,percent of total billed charges,75% of total billed charges,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.08 ,80,,,percent of total billed charges,80% of total billed charges,$17.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.99 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$50.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.26 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.99 ,$53.53 ,
SUTURE ETHILON 3-0 (1669H),12509,CDM,270,RC,,HCPCS,outpatient,,,$12.96 ,$4.54 ,,$6.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.72 ,75,,,percent of total billed charges,75% of total billed charges,$9.72 ,75,,,percent of total billed charges,75% of total billed charges,$9.72 ,75,,,percent of total billed charges,75% of total billed charges,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.37 ,80,,,percent of total billed charges,80% of total billed charges,$4.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.54 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.37 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.07 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.37 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.53 ,$12.31 ,
SUTURE ETHILON 4-0 699G,11482,CDM,270,RC,,HCPCS,outpatient,,,$13.20 ,$4.62 ,,$7.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.56 ,80,,,percent of total billed charges,80% of total billed charges,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.57 ,$12.54 ,
SUTURE ETHILON 4-0 662H,11476,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE ETHILON 4-0 699H,11481,CDM,270,RC,,HCPCS,outpatient,,,$13.20 ,$4.62 ,,$7.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$9.90 ,75,,,percent of total billed charges,75% of total billed charges,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.56 ,80,,,percent of total billed charges,80% of total billed charges,$4.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.16 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.09 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.88 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.90 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.57 ,$12.54 ,
SUTURE ETHILON 5-0 661H,11475,CDM,270,RC,,HCPCS,outpatient,,,$14.07 ,$4.92 ,,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$10.55 ,75,,,percent of total billed charges,75% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges,$4.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.74 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$12.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.74 ,$13.37 ,
SUTURE ETHILON 5-0 698G,11483,CDM,270,RC,,HCPCS,outpatient,,,$106.30 ,$37.21 ,,$56.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$56.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.73 ,75,,,percent of total billed charges,75% of total billed charges,$79.73 ,75,,,percent of total billed charges,75% of total billed charges,$79.73 ,75,,,percent of total billed charges,75% of total billed charges,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.04 ,80,,,percent of total billed charges,80% of total billed charges,$33.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$95.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$100.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.86 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$79.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.73 ,$100.99 ,
SUTURE ETHILON 5-0 BLACK,11470,CDM,270,RC,,HCPCS,outpatient,,,$102.66 ,$35.93 ,,$55.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.00 ,75,,,percent of total billed charges,75% of total billed charges,$77.00 ,75,,,percent of total billed charges,75% of total billed charges,$77.00 ,75,,,percent of total billed charges,75% of total billed charges,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.13 ,80,,,percent of total billed charges,80% of total billed charges,$32.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$92.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$77.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.02 ,$97.53 ,
SUTURE ETHILON 6-0 (697G),11472,CDM,270,RC,,HCPCS,outpatient,,,$109.15 ,$38.20 ,,$58.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.86 ,75,,,percent of total billed charges,75% of total billed charges,$81.86 ,75,,,percent of total billed charges,75% of total billed charges,$81.86 ,75,,,percent of total billed charges,75% of total billed charges,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.32 ,80,,,percent of total billed charges,80% of total billed charges,$34.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.69 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.28 ,$103.69 ,
SUTURE ETHILON 6-0 1660G,11768,CDM,272,RC,,HCPCS,outpatient,,,$63.00 ,$22.05 ,,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.29 ,$59.85 ,
SUTURE ETHILON 626H,11979,CDM,270,RC,,HCPCS,outpatient,,,$59.16 ,$20.71 ,,$31.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.37 ,75,,,percent of total billed charges,75% of total billed charges,$44.37 ,75,,,percent of total billed charges,75% of total billed charges,$44.37 ,75,,,percent of total billed charges,75% of total billed charges,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.33 ,80,,,percent of total billed charges,80% of total billed charges,$18.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.71 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$45.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.33 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.54 ,$56.20 ,
SUTURE ETHILON 627H,11978,CDM,270,RC,,HCPCS,outpatient,,,$58.33 ,$20.42 ,,$31.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.75 ,75,,,percent of total billed charges,75% of total billed charges,$43.75 ,75,,,percent of total billed charges,75% of total billed charges,$43.75 ,75,,,percent of total billed charges,75% of total billed charges,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.66 ,80,,,percent of total billed charges,80% of total billed charges,$18.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$52.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$55.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.37 ,$55.41 ,
SUTURE ETHILON 668G,11479,CDM,270,RC,,HCPCS,outpatient,,,$48.59 ,$17.01 ,,$26.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.44 ,75,,,percent of total billed charges,75% of total billed charges,$36.44 ,75,,,percent of total billed charges,75% of total billed charges,$36.44 ,75,,,percent of total billed charges,75% of total billed charges,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.87 ,80,,,percent of total billed charges,80% of total billed charges,$15.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.01 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.87 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.48 ,$46.16 ,
SUTURE ETHILON 7-0,11590,CDM,270,RC,,HCPCS,outpatient,,,$125.93 ,$44.08 ,,$67.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.45 ,75,,,percent of total billed charges,75% of total billed charges,$94.45 ,75,,,percent of total billed charges,75% of total billed charges,$94.45 ,75,,,percent of total billed charges,75% of total billed charges,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$100.74 ,80,,,percent of total billed charges,80% of total billed charges,$39.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$100.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$113.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$94.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$94.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.56 ,$119.63 ,
SUTURE ETHILON BLK 1696G,93012,CDM,272,RC,,HCPCS,outpatient,,,$14.98 ,$5.24 ,,$8.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.24 ,75,,,percent of total billed charges,75% of total billed charges,$11.24 ,75,,,percent of total billed charges,75% of total billed charges,$11.24 ,75,,,percent of total billed charges,75% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.98 ,80,,,percent of total billed charges,80% of total billed charges,$4.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.24 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.48 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.73 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.92 ,$14.23 ,
SUTURE MERSILENE LIG 5MM X 30CM  RS20,11872,CDM,270,RC,,HCPCS,outpatient,,,$695.25 ,$243.34 ,,$372.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$372.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$521.44 ,75,,,percent of total billed charges,75% of total billed charges,$521.44 ,75,,,percent of total billed charges,75% of total billed charges,$521.44 ,75,,,percent of total billed charges,75% of total billed charges,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$556.20 ,80,,,percent of total billed charges,80% of total billed charges,$219.84 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$243.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$217.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$556.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$486.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$486.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$535.34 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$217.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$217.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$217.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$215.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$625.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$139.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$660.49 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$556.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$646.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$521.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$521.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$521.44 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$590.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.57 ,$660.49 ,
SUTURE MERSILENE LIG 5MM X 30CM  MR21T,11489,CDM,270,RC,,HCPCS,outpatient,,,$293.89 ,$102.86 ,,$157.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$157.53 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$220.42 ,75,,,percent of total billed charges,75% of total billed charges,$220.42 ,75,,,percent of total billed charges,75% of total billed charges,$220.42 ,75,,,percent of total billed charges,75% of total billed charges,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$235.11 ,80,,,percent of total billed charges,80% of total billed charges,$92.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$102.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$235.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$205.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$226.30 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.31 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$264.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$279.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.11 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$273.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$220.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$220.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$220.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$249.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.45 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.31 ,$279.20 ,
SUTURE MERSILENE R424H,12816,CDM,270,RC,,HCPCS,outpatient,,,$57.46 ,$20.11 ,,$30.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$43.10 ,75,,,percent of total billed charges,75% of total billed charges,$43.10 ,75,,,percent of total billed charges,75% of total billed charges,$43.10 ,75,,,percent of total billed charges,75% of total billed charges,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.97 ,80,,,percent of total billed charges,80% of total billed charges,$18.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$40.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.44 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$43.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.20 ,$54.59 ,
SUTURE MONOCRYL Y214,28557,CDM,270,RC,,HCPCS,outpatient,,,$62.46 ,$21.86 ,,$33.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.85 ,75,,,percent of total billed charges,75% of total billed charges,$46.85 ,75,,,percent of total billed charges,75% of total billed charges,$46.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.97 ,80,,,percent of total billed charges,80% of total billed charges,$19.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.86 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$46.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$46.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.18 ,$59.34 ,
SUTURE MONOCRYL Y426H,12553,CDM,270,RC,,HCPCS,outpatient,,,$56.21 ,$19.67 ,,$30.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.16 ,75,,,percent of total billed charges,75% of total billed charges,$42.16 ,75,,,percent of total billed charges,75% of total billed charges,$42.16 ,75,,,percent of total billed charges,75% of total billed charges,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.97 ,80,,,percent of total billed charges,80% of total billed charges,$17.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$19.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$50.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.96 ,$53.40 ,
SUTURE MONOCRYL Y427,12611,CDM,270,RC,,HCPCS,outpatient,,,$147.50 ,$51.63 ,,$79.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.63 ,75,,,percent of total billed charges,75% of total billed charges,$110.63 ,75,,,percent of total billed charges,75% of total billed charges,$110.63 ,75,,,percent of total billed charges,75% of total billed charges,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$118.00 ,80,,,percent of total billed charges,80% of total billed charges,$46.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$51.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$118.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$103.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.76 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$45.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$132.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$140.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$110.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.62 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$125.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.76 ,$140.13 ,
SUTURE NYLON 4-0  1629H,11828,CDM,270,RC,,HCPCS,outpatient,,,$57.13 ,$20.00 ,,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$30.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.85 ,75,,,percent of total billed charges,75% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges,$18.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$43.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$17.71 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$51.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$54.27 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.56 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.14 ,$54.27 ,
SUTURE NYLON 6.0,11640,CDM,270,RC,,HCPCS,outpatient,,,$106.49 ,$37.27 ,,$57.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$57.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.87 ,75,,,percent of total billed charges,75% of total billed charges,$79.87 ,75,,,percent of total billed charges,75% of total billed charges,$79.87 ,75,,,percent of total billed charges,75% of total billed charges,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$85.19 ,80,,,percent of total billed charges,80% of total billed charges,$33.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$37.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$82.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$95.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$101.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$79.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.77 ,$101.17 ,
SUTURE PDS 0 PDP370T,12567,CDM,270,RC,,HCPCS,outpatient,,,$88.20 ,$30.87 ,,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$66.15 ,75,,,percent of total billed charges,75% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges,$27.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$79.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$83.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$74.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.20 ,$83.79 ,
SUTURE PDS 0 Z990G,12685,CDM,270,RC,,HCPCS,outpatient,,,$89.94 ,$31.48 ,,$48.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$48.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$67.46 ,75,,,percent of total billed charges,75% of total billed charges,$67.46 ,75,,,percent of total billed charges,75% of total billed charges,$67.46 ,75,,,percent of total billed charges,75% of total billed charges,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.95 ,80,,,percent of total billed charges,80% of total billed charges,$28.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.96 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$80.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$85.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.64 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$67.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$67.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.54 ,$85.44 ,
SUTURE PDS 3-0,11526,CDM,270,RC,,HCPCS,outpatient,,,$101.38 ,$35.48 ,,$54.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.04 ,75,,,percent of total billed charges,75% of total billed charges,$76.04 ,75,,,percent of total billed charges,75% of total billed charges,$76.04 ,75,,,percent of total billed charges,75% of total billed charges,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.10 ,80,,,percent of total billed charges,80% of total billed charges,$32.06 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.31 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.17 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.77 ,$96.31 ,
SUTURE PDS 4-0,11502,CDM,270,RC,,HCPCS,outpatient,,,$109.93 ,$38.48 ,,$58.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.45 ,75,,,percent of total billed charges,75% of total billed charges,$82.45 ,75,,,percent of total billed charges,75% of total billed charges,$82.45 ,75,,,percent of total billed charges,75% of total billed charges,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.94 ,80,,,percent of total billed charges,80% of total billed charges,$34.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.07 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.44 ,$104.43 ,
SUTURE PDS II #1 Z371T,12569,CDM,270,RC,,HCPCS,outpatient,,,$20.13 ,$7.05 ,,$10.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.79 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.10 ,75,,,percent of total billed charges,75% of total billed charges,$15.10 ,75,,,percent of total billed charges,75% of total billed charges,$15.10 ,75,,,percent of total billed charges,75% of total billed charges,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.10 ,80,,,percent of total billed charges,80% of total billed charges,$6.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.09 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$18.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.10 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.72 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$15.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.00 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.93 ,$19.12 ,
SUTURE PDS II 4-0  Z494G,11748,CDM,270,RC,,HCPCS,outpatient,,,$141.14 ,$49.40 ,,$75.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.86 ,75,,,percent of total billed charges,75% of total billed charges,$105.86 ,75,,,percent of total billed charges,75% of total billed charges,$105.86 ,75,,,percent of total billed charges,75% of total billed charges,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.91 ,80,,,percent of total billed charges,80% of total billed charges,$44.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$127.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$134.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.52 ,$134.08 ,
SUTURE PDS II 4-0  Z682G,11799,CDM,270,RC,,HCPCS,outpatient,,,$160.61 ,$56.21 ,,$86.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$86.09 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$120.46 ,75,,,percent of total billed charges,75% of total billed charges,$120.46 ,75,,,percent of total billed charges,75% of total billed charges,$120.46 ,75,,,percent of total billed charges,75% of total billed charges,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.49 ,80,,,percent of total billed charges,80% of total billed charges,$50.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$128.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$112.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$144.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$152.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$120.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$120.46 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.32 ,$152.58 ,
SUTURE PDS II 4-0  Z340H,11703,CDM,270,RC,,HCPCS,outpatient,,,$71.98 ,$25.19 ,,$38.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.99 ,75,,,percent of total billed charges,75% of total billed charges,$53.99 ,75,,,percent of total billed charges,75% of total billed charges,$53.99 ,75,,,percent of total billed charges,75% of total billed charges,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.58 ,80,,,percent of total billed charges,80% of total billed charges,$22.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.19 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.39 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.04 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.04 ,$68.38 ,
SUTURE PDS II 4-0  Z310H,12623,CDM,270,RC,,HCPCS,outpatient,,,$84.20 ,$29.47 ,,$45.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.15 ,75,,,percent of total billed charges,75% of total billed charges,$63.15 ,75,,,percent of total billed charges,75% of total billed charges,$63.15 ,75,,,percent of total billed charges,75% of total billed charges,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.36 ,80,,,percent of total billed charges,80% of total billed charges,$26.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$75.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.31 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$63.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.91 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.42 ,$79.99 ,
SUTURE PDS II 5-0,11746,CDM,270,RC,,HCPCS,outpatient,,,$163.00 ,$57.05 ,,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$122.25 ,75,,,percent of total billed charges,75% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges,$51.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$57.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$125.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$50.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$146.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$151.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$122.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$138.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.79 ,$154.85 ,
SUTURE PLAIN GUT 0,11671,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE PLAIN GUT 2-0,11860,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE PLAIN GUT 3-0  L102G,11568,CDM,270,RC,,HCPCS,outpatient,,,$96.36 ,$33.73 ,,$51.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$72.27 ,75,,,percent of total billed charges,75% of total billed charges,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.09 ,80,,,percent of total billed charges,80% of total billed charges,$30.47 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.87 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.09 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.27 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.79 ,$91.54 ,
SUTURE PLAIN GUT 3-0 852H,11504,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE PLAIN GUT 3-0  G322H,11567,CDM,270,RC,,HCPCS,outpatient,,,$86.52 ,$30.28 ,,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$46.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$64.89 ,75,,,percent of total billed charges,75% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges,$27.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$30.28 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$60.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.62 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$77.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.22 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$64.89 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$73.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.87 ,$82.19 ,
SUTURE PLAIN GUT 3-0 665H,11503,CDM,270,RC,,HCPCS,outpatient,,,$88.63 ,$31.02 ,,$47.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.47 ,75,,,percent of total billed charges,75% of total billed charges,$66.47 ,75,,,percent of total billed charges,75% of total billed charges,$66.47 ,75,,,percent of total billed charges,75% of total billed charges,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.90 ,80,,,percent of total billed charges,80% of total billed charges,$28.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$31.02 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$62.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$27.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$79.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$17.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$17.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$66.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$66.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.80 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$17.28 ,$84.20 ,
SUTURE PLAIN GUT 3-0  52T,11660,CDM,270,RC,,HCPCS,outpatient,,,$175.67 ,$61.48 ,,$94.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$94.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.75 ,75,,,percent of total billed charges,75% of total billed charges,$131.75 ,75,,,percent of total billed charges,75% of total billed charges,$131.75 ,75,,,percent of total billed charges,75% of total billed charges,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$140.54 ,80,,,percent of total billed charges,80% of total billed charges,$55.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.48 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$140.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$135.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$158.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$166.89 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$140.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$149.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.26 ,$166.89 ,
SUTURE PROLENE 0  8434H,11834,CDM,270,RC,,HCPCS,outpatient,,,$71.51 ,$25.03 ,,$38.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.33 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.63 ,75,,,percent of total billed charges,75% of total billed charges,$53.63 ,75,,,percent of total billed charges,75% of total billed charges,$53.63 ,75,,,percent of total billed charges,75% of total billed charges,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.21 ,80,,,percent of total billed charges,80% of total billed charges,$22.61 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.03 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.36 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.78 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.94 ,$67.93 ,
SUTURE PROLENE 0  8412H,11833,CDM,270,RC,,HCPCS,outpatient,,,$71.58 ,$25.05 ,,$38.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.69 ,75,,,percent of total billed charges,75% of total billed charges,$53.69 ,75,,,percent of total billed charges,75% of total billed charges,$53.69 ,75,,,percent of total billed charges,75% of total billed charges,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.26 ,80,,,percent of total billed charges,80% of total billed charges,$22.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.96 ,$68.00 ,
SUTURE PROLENE 0  8834H,12817,CDM,270,RC,,HCPCS,outpatient,,,$99.42 ,$34.80 ,,$53.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$74.57 ,75,,,percent of total billed charges,75% of total billed charges,$74.57 ,75,,,percent of total billed charges,75% of total billed charges,$74.57 ,75,,,percent of total billed charges,75% of total billed charges,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$79.54 ,80,,,percent of total billed charges,80% of total billed charges,$31.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$69.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.82 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$89.48 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.54 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.46 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$74.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$74.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$84.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.39 ,$94.45 ,
SUTURE PROLENE 0 8424H,11501,CDM,270,RC,,HCPCS,outpatient,,,$70.97 ,$24.84 ,,$38.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$53.23 ,75,,,percent of total billed charges,75% of total billed charges,$53.23 ,75,,,percent of total billed charges,75% of total billed charges,$53.23 ,75,,,percent of total billed charges,75% of total billed charges,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.78 ,80,,,percent of total billed charges,80% of total billed charges,$22.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.68 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$54.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.87 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.42 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$53.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.23 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$60.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.84 ,$67.42 ,
SUTURE PROLENE 0 8444H,11491,CDM,270,RC,,HCPCS,outpatient,,,$93.54 ,$32.74 ,,$50.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.16 ,75,,,percent of total billed charges,75% of total billed charges,$70.16 ,75,,,percent of total billed charges,75% of total billed charges,$70.16 ,75,,,percent of total billed charges,75% of total billed charges,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.83 ,80,,,percent of total billed charges,80% of total billed charges,$29.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.03 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$84.19 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.99 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$70.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.24 ,$88.86 ,
SUTURE PROLENE 1 8435H,11492,CDM,270,RC,,HCPCS,outpatient,,,$72.14 ,$25.25 ,,$38.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.11 ,75,,,percent of total billed charges,75% of total billed charges,$54.11 ,75,,,percent of total billed charges,75% of total billed charges,$54.11 ,75,,,percent of total billed charges,75% of total billed charges,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.71 ,80,,,percent of total billed charges,80% of total billed charges,$22.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$25.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$22.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$22.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$64.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.71 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.09 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$54.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$54.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$61.32 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.07 ,$68.53 ,
SUTURE PROLENE 1 8190G,11494,CDM,270,RC,,HCPCS,outpatient,,,$209.46 ,$73.31 ,,$112.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$157.10 ,75,,,percent of total billed charges,75% of total billed charges,$157.10 ,75,,,percent of total billed charges,75% of total billed charges,$157.10 ,75,,,percent of total billed charges,75% of total billed charges,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.57 ,80,,,percent of total billed charges,80% of total billed charges,$66.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$73.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$167.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$146.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$161.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$65.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$64.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$188.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$42.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$198.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$167.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$157.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$157.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$157.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$42.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$178.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.66 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.84 ,$198.99 ,
SUTURE PROLENE 10.0,11763,CDM,270,RC,,HCPCS,outpatient,,,$480.42 ,$168.15 ,,$257.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.32 ,75,,,percent of total billed charges,75% of total billed charges,$360.32 ,75,,,percent of total billed charges,75% of total billed charges,$360.32 ,75,,,percent of total billed charges,75% of total billed charges,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.34 ,80,,,percent of total billed charges,80% of total billed charges,$151.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.42 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.36 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.68 ,$456.40 ,
SUTURE PROLENE 2-0  8571G,11694,CDM,270,RC,,HCPCS,outpatient,,,$156.42 ,$54.75 ,,$83.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.32 ,75,,,percent of total billed charges,75% of total billed charges,$117.32 ,75,,,percent of total billed charges,75% of total billed charges,$117.32 ,75,,,percent of total billed charges,75% of total billed charges,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.14 ,80,,,percent of total billed charges,80% of total billed charges,$49.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$109.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$120.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$140.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$117.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.11 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.50 ,$148.60 ,
SUTURE PROLENE 2-0 8833H,11490,CDM,270,RC,,HCPCS,outpatient,,,$66.14 ,$23.15 ,,$35.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.45 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.61 ,75,,,percent of total billed charges,75% of total billed charges,$49.61 ,75,,,percent of total billed charges,75% of total billed charges,$49.61 ,75,,,percent of total billed charges,75% of total billed charges,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.91 ,80,,,percent of total billed charges,80% of total billed charges,$20.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$59.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.16 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.90 ,$62.83 ,
SUTURE PROLENE 2-03846T,11835,CDM,270,RC,,HCPCS,outpatient,,,$223.45 ,$78.21 ,,$119.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$167.59 ,75,,,percent of total billed charges,75% of total billed charges,$167.59 ,75,,,percent of total billed charges,75% of total billed charges,$167.59 ,75,,,percent of total billed charges,75% of total billed charges,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$178.76 ,80,,,percent of total billed charges,80% of total billed charges,$70.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$78.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$178.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$156.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.42 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.06 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$69.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.57 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$69.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$201.11 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$44.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$212.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.76 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$167.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$167.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$189.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.57 ,$212.28 ,
SUTURE PROLENE 3-0  8665G,11963,CDM,270,RC,,HCPCS,outpatient,,,$11.15 ,$3.90 ,,$5.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.36 ,75,,,percent of total billed charges,75% of total billed charges,$8.36 ,75,,,percent of total billed charges,75% of total billed charges,$8.36 ,75,,,percent of total billed charges,75% of total billed charges,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.92 ,80,,,percent of total billed charges,80% of total billed charges,$3.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.81 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.37 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.17 ,$10.59 ,
SUTURE PROLENE 3-0 8872H,11500,CDM,270,RC,,HCPCS,outpatient,,,$98.35 ,$34.42 ,,$52.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$52.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$73.76 ,75,,,percent of total billed charges,75% of total billed charges,$73.76 ,75,,,percent of total billed charges,75% of total billed charges,$73.76 ,75,,,percent of total billed charges,75% of total billed charges,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.68 ,80,,,percent of total billed charges,80% of total billed charges,$31.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$34.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$78.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$68.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$75.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$88.52 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.47 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$73.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$83.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.18 ,$93.43 ,
SUTURE PROLENE 3-0 8832H,11493,CDM,270,RC,,HCPCS,outpatient,,,$95.59 ,$33.46 ,,$51.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.69 ,75,,,percent of total billed charges,75% of total billed charges,$71.69 ,75,,,percent of total billed charges,75% of total billed charges,$71.69 ,75,,,percent of total billed charges,75% of total billed charges,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.47 ,80,,,percent of total billed charges,80% of total billed charges,$30.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$66.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$66.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.64 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$90.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.47 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.64 ,$90.81 ,
SUTURE PROLENE 4-0 8831H,11497,CDM,270,RC,,HCPCS,outpatient,,,$134.47 ,$47.06 ,,$72.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$100.85 ,75,,,percent of total billed charges,75% of total billed charges,$100.85 ,75,,,percent of total billed charges,75% of total billed charges,$100.85 ,75,,,percent of total billed charges,75% of total billed charges,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$107.58 ,80,,,percent of total billed charges,80% of total billed charges,$42.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$47.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$94.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$103.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$42.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$41.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$121.02 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.58 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$100.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$100.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.22 ,$127.75 ,
SUTURE PROLENE 5-0 8870H,11682,CDM,270,RC,,HCPCS,outpatient,,,$38.37 ,$13.43 ,,$20.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.57 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.78 ,75,,,percent of total billed charges,75% of total billed charges,$28.78 ,75,,,percent of total billed charges,75% of total billed charges,$28.78 ,75,,,percent of total billed charges,75% of total billed charges,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.70 ,80,,,percent of total billed charges,80% of total billed charges,$12.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.43 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.61 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.48 ,$36.45 ,
SUTURE PROLENE 5-0 8681G,11174,CDM,270,RC,,HCPCS,outpatient,,,$128.25 ,$44.89 ,,$68.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.74 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$96.19 ,75,,,percent of total billed charges,75% of total billed charges,$96.19 ,75,,,percent of total billed charges,75% of total billed charges,$96.19 ,75,,,percent of total billed charges,75% of total billed charges,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$102.60 ,80,,,percent of total billed charges,80% of total billed charges,$40.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$89.78 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.16 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.01 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$115.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$121.84 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$96.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.75 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$109.01 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.01 ,$121.84 ,
SUTURE PROLENE 5-0 8713H,11498,CDM,270,RC,,HCPCS,outpatient,,,$143.57 ,$50.25 ,,$76.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.95 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$107.68 ,75,,,percent of total billed charges,75% of total billed charges,$107.68 ,75,,,percent of total billed charges,75% of total billed charges,$107.68 ,75,,,percent of total billed charges,75% of total billed charges,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.86 ,80,,,percent of total billed charges,80% of total billed charges,$45.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$44.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.21 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.52 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$107.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$107.68 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.00 ,$136.39 ,
SUTURE PROLENE 6-0 8680G,11499,CDM,270,RC,,HCPCS,outpatient,,,$149.88 ,$52.46 ,,$80.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.41 ,75,,,percent of total billed charges,75% of total billed charges,$112.41 ,75,,,percent of total billed charges,75% of total billed charges,$112.41 ,75,,,percent of total billed charges,75% of total billed charges,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.90 ,80,,,percent of total billed charges,80% of total billed charges,$47.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$134.89 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.23 ,$142.39 ,
SUTURE PROLENE 6-0  8606G,11807,CDM,270,RC,,HCPCS,outpatient,,,$159.50 ,$55.83 ,,$85.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.63 ,75,,,percent of total billed charges,75% of total billed charges,$119.63 ,75,,,percent of total billed charges,75% of total billed charges,$119.63 ,75,,,percent of total billed charges,75% of total billed charges,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.60 ,80,,,percent of total billed charges,80% of total billed charges,$50.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$55.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.53 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.10 ,$151.53 ,
SUTURE PROLENE 6-0 8714H,11495,CDM,270,RC,,HCPCS,outpatient,,,$148.80 ,$52.08 ,,$79.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$79.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$111.60 ,75,,,percent of total billed charges,75% of total billed charges,$111.60 ,75,,,percent of total billed charges,75% of total billed charges,$111.60 ,75,,,percent of total billed charges,75% of total billed charges,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.04 ,80,,,percent of total billed charges,80% of total billed charges,$47.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.16 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$114.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.02 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$133.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.36 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$111.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$111.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$126.48 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.02 ,$141.36 ,
SUTURE PROLENE 7-0,11806,CDM,270,RC,,HCPCS,outpatient,,,$159.99 ,$56.00 ,,$85.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$85.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$119.99 ,75,,,percent of total billed charges,75% of total billed charges,$119.99 ,75,,,percent of total billed charges,75% of total billed charges,$119.99 ,75,,,percent of total billed charges,75% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$127.99 ,80,,,percent of total billed charges,80% of total billed charges,$50.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$56.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$123.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$50.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$49.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$143.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$151.99 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.99 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$119.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$119.99 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$135.99 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,$151.99 ,
SUTURE PROLENE 8425H,12874,CDM,270,RC,,HCPCS,outpatient,,,$17.58 ,$6.15 ,,$9.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.19 ,75,,,percent of total billed charges,75% of total billed charges,$13.19 ,75,,,percent of total billed charges,75% of total billed charges,$13.19 ,75,,,percent of total billed charges,75% of total billed charges,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.06 ,80,,,percent of total billed charges,80% of total billed charges,$5.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.43 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.19 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.43 ,$16.70 ,
SUTURE REMOVAL TRAY,11156,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE SILK 0  680H,11755,CDM,270,RC,,HCPCS,outpatient,,,$48.20 ,$16.87 ,,$25.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.15 ,75,,,percent of total billed charges,75% of total billed charges,$36.15 ,75,,,percent of total billed charges,75% of total billed charges,$36.15 ,75,,,percent of total billed charges,75% of total billed charges,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.56 ,80,,,percent of total billed charges,80% of total billed charges,$15.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$43.38 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.79 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.15 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.97 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.59 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.40 ,$45.79 ,
SUTURE SILK 0 K834H,11523,CDM,270,RC,,HCPCS,outpatient,,,$36.86 ,$12.90 ,,$19.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.65 ,75,,,percent of total billed charges,75% of total billed charges,$27.65 ,75,,,percent of total billed charges,75% of total billed charges,$27.65 ,75,,,percent of total billed charges,75% of total billed charges,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.49 ,80,,,percent of total billed charges,80% of total billed charges,$11.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.38 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.19 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.02 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.49 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.19 ,$35.02 ,
SUTURE SILK 2 ( D4168),11356,CDM,270,RC,,HCPCS,outpatient,,,$124.08 ,$43.43 ,,$66.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$66.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.06 ,75,,,percent of total billed charges,75% of total billed charges,$93.06 ,75,,,percent of total billed charges,75% of total billed charges,$93.06 ,75,,,percent of total billed charges,75% of total billed charges,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$99.26 ,80,,,percent of total billed charges,80% of total billed charges,$39.23 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.43 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.86 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$95.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$38.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$38.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$111.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$24.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$93.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$93.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$105.47 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.20 ,$117.88 ,
SUTURE SILK 2-0  482T,11867,CDM,270,RC,,HCPCS,outpatient,,,$95.90 ,$33.57 ,,$51.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$71.93 ,75,,,percent of total billed charges,75% of total billed charges,$71.93 ,75,,,percent of total billed charges,75% of total billed charges,$71.93 ,75,,,percent of total billed charges,75% of total billed charges,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.72 ,80,,,percent of total billed charges,80% of total billed charges,$30.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.57 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$76.72 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.13 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$73.84 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$29.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$86.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$91.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.72 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$71.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$71.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$81.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.70 ,$91.11 ,
SUTURE SILK 2-0  K883H,11859,CDM,270,RC,,HCPCS,outpatient,,,$61.29 ,$21.45 ,,$32.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$45.97 ,75,,,percent of total billed charges,75% of total billed charges,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.03 ,80,,,percent of total billed charges,80% of total billed charges,$19.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$55.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$52.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.95 ,$58.23 ,
SUTURE SILK 2-0 (C012D),11505,CDM,270,RC,,HCPCS,outpatient,,,$60.39 ,$21.14 ,,$32.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.37 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.29 ,75,,,percent of total billed charges,75% of total billed charges,$45.29 ,75,,,percent of total billed charges,75% of total billed charges,$45.29 ,75,,,percent of total billed charges,75% of total billed charges,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.31 ,80,,,percent of total billed charges,80% of total billed charges,$19.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.37 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.29 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.13 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.78 ,$57.37 ,
SUTURE SILK 2-0 (SA85H),11855,CDM,270,RC,,HCPCS,outpatient,,,$67.53 ,$23.64 ,,$36.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.65 ,75,,,percent of total billed charges,75% of total billed charges,$50.65 ,75,,,percent of total billed charges,75% of total billed charges,$50.65 ,75,,,percent of total billed charges,75% of total billed charges,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$54.02 ,80,,,percent of total billed charges,80% of total billed charges,$21.35 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$47.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.17 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$64.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.17 ,$64.15 ,
SUTURE SILK 2-0 423H,11510,CDM,270,RC,,HCPCS,outpatient,,,$37.55 ,$13.14 ,,$20.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.13 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.16 ,75,,,percent of total billed charges,75% of total billed charges,$28.16 ,75,,,percent of total billed charges,75% of total billed charges,$28.16 ,75,,,percent of total billed charges,75% of total billed charges,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.04 ,80,,,percent of total billed charges,80% of total billed charges,$11.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.29 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.91 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.67 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.04 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.16 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.32 ,$35.67 ,
SUTURE SILK 2-0 685G,11516,CDM,270,RC,,HCPCS,outpatient,,,$45.50 ,$15.93 ,,$24.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.40 ,80,,,percent of total billed charges,80% of total billed charges,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.87 ,$43.23 ,
SUTURE SILK 2-0 K853H,11520,CDM,270,RC,,HCPCS,outpatient,,,$22.23 ,$7.78 ,,$11.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.67 ,75,,,percent of total billed charges,75% of total billed charges,$16.67 ,75,,,percent of total billed charges,75% of total billed charges,$16.67 ,75,,,percent of total billed charges,75% of total billed charges,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.78 ,80,,,percent of total billed charges,80% of total billed charges,$7.03 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.78 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.56 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.12 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.67 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.67 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.33 ,$21.12 ,
SUTURE SILK 2-0 K833H,11518,CDM,270,RC,,HCPCS,outpatient,,,$36.19 ,$12.67 ,,$19.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.14 ,75,,,percent of total billed charges,75% of total billed charges,$27.14 ,75,,,percent of total billed charges,75% of total billed charges,$27.14 ,75,,,percent of total billed charges,75% of total billed charges,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.95 ,80,,,percent of total billed charges,80% of total billed charges,$11.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.67 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.06 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.22 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.14 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.06 ,$34.38 ,
SUTURE SILK 2-0 SA65H,11511,CDM,270,RC,,HCPCS,outpatient,,,$66.19 ,$23.17 ,,$35.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.95 ,80,,,percent of total billed charges,80% of total billed charges,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$59.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.91 ,$62.88 ,
SUTURE SILK 3-0  C013D,11880,CDM,270,RC,,HCPCS,outpatient,,,$60.00 ,$21.00 ,,$32.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.00 ,75,,,percent of total billed charges,75% of total billed charges,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.00 ,80,,,percent of total billed charges,80% of total billed charges,$18.97 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.20 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.79 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.60 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.70 ,$57.00 ,
SUTURE SILK 3-0 632G,11524,CDM,270,RC,,HCPCS,outpatient,,,$47.29 ,$16.55 ,,$25.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.47 ,75,,,percent of total billed charges,75% of total billed charges,$35.47 ,75,,,percent of total billed charges,75% of total billed charges,$35.47 ,75,,,percent of total billed charges,75% of total billed charges,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.83 ,80,,,percent of total billed charges,80% of total billed charges,$14.95 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.66 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.56 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.22 ,$44.93 ,
SUTURE SILK 3-0 675H,11525,CDM,270,RC,,HCPCS,outpatient,,,$49.29 ,$17.25 ,,$26.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.97 ,75,,,percent of total billed charges,75% of total billed charges,$36.97 ,75,,,percent of total billed charges,75% of total billed charges,$36.97 ,75,,,percent of total billed charges,75% of total billed charges,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.43 ,80,,,percent of total billed charges,80% of total billed charges,$15.59 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.61 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$44.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.83 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.61 ,$46.83 ,
SUTURE SILK 3-0 684H,11509,CDM,270,RC,,HCPCS,outpatient,,,$31.29 ,$10.95 ,,$16.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.47 ,75,,,percent of total billed charges,75% of total billed charges,$23.47 ,75,,,percent of total billed charges,75% of total billed charges,$23.47 ,75,,,percent of total billed charges,75% of total billed charges,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.03 ,80,,,percent of total billed charges,80% of total billed charges,$9.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.16 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.03 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.10 ,$29.73 ,
SUTURE SILK 3-0 K832H,11517,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE SILK 3-0 SA74H,11508,CDM,270,RC,,HCPCS,outpatient,,,$68.96 ,$24.14 ,,$36.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.72 ,75,,,percent of total billed charges,75% of total billed charges,$51.72 ,75,,,percent of total billed charges,75% of total billed charges,$51.72 ,75,,,percent of total billed charges,75% of total billed charges,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.17 ,80,,,percent of total billed charges,80% of total billed charges,$21.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$55.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.10 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$62.06 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$65.51 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$51.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$58.62 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.45 ,$65.51 ,
SUTURE SILK 4-0,11766,CDM,272,RC,,HCPCS,outpatient,,,$63.00 ,$22.05 ,,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.29 ,$59.85 ,
SUTURE SILK 4-0 683G,11528,CDM,270,RC,,HCPCS,outpatient,,,$10.64 ,$3.72 ,,$5.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$7.98 ,75,,,percent of total billed charges,75% of total billed charges,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.51 ,80,,,percent of total billed charges,80% of total billed charges,$3.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.11 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.98 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.07 ,$10.11 ,
SUTURE SILK 4-0 SA63H,11512,CDM,270,RC,,HCPCS,outpatient,,,$66.19 ,$23.17 ,,$35.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$49.64 ,75,,,percent of total billed charges,75% of total billed charges,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.95 ,80,,,percent of total billed charges,80% of total billed charges,$20.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$52.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$50.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$20.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.91 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.52 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$59.57 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$62.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.29 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.91 ,$62.88 ,
SUTURE SILK 4-K831H,11513,CDM,270,RC,,HCPCS,outpatient,,,$36.95 ,$12.93 ,,$19.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.71 ,75,,,percent of total billed charges,75% of total billed charges,$27.71 ,75,,,percent of total billed charges,75% of total billed charges,$27.71 ,75,,,percent of total billed charges,75% of total billed charges,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.56 ,80,,,percent of total billed charges,80% of total billed charges,$11.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.21 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.21 ,$35.10 ,
SUTURE SILK 424H,12552,CDM,270,RC,,HCPCS,outpatient,,,$36.70 ,$12.85 ,,$19.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.67 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.53 ,75,,,percent of total billed charges,75% of total billed charges,$27.53 ,75,,,percent of total billed charges,75% of total billed charges,$27.53 ,75,,,percent of total billed charges,75% of total billed charges,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.36 ,80,,,percent of total billed charges,80% of total billed charges,$11.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.69 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.03 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.36 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.13 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.53 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.37 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.16 ,$34.87 ,
SUTURE SILK 5-0,11507,CDM,270,RC,,HCPCS,outpatient,,,$49.04 ,$17.16 ,,$26.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.29 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$36.78 ,75,,,percent of total billed charges,75% of total billed charges,$36.78 ,75,,,percent of total billed charges,75% of total billed charges,$36.78 ,75,,,percent of total billed charges,75% of total billed charges,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.23 ,80,,,percent of total billed charges,80% of total billed charges,$15.51 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.33 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$44.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.59 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.23 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$36.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.78 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.56 ,$46.59 ,
SUTURE SILK 6-0 681G,11506,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE SILK 6-0 681H,11519,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE SILK 622H,11544,CDM,270,RC,,HCPCS,outpatient,,,$46.17 ,$16.16 ,,$24.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.63 ,75,,,percent of total billed charges,75% of total billed charges,$34.63 ,75,,,percent of total billed charges,75% of total billed charges,$34.63 ,75,,,percent of total billed charges,75% of total billed charges,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.94 ,80,,,percent of total billed charges,80% of total billed charges,$14.60 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.55 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.94 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.24 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.00 ,$43.86 ,
SUTURE SILK 8-0,11767,CDM,272,RC,,HCPCS,outpatient,,,$63.00 ,$22.05 ,,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$47.25 ,75,,,percent of total billed charges,75% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges,$19.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$22.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$44.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$48.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$19.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$56.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$47.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$53.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.29 ,$59.85 ,
SUTURE SILK K835H,12418,CDM,270,RC,,HCPCS,outpatient,,,$45.93 ,$16.08 ,,$24.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.45 ,75,,,percent of total billed charges,75% of total billed charges,$34.45 ,75,,,percent of total billed charges,75% of total billed charges,$34.45 ,75,,,percent of total billed charges,75% of total billed charges,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.74 ,80,,,percent of total billed charges,80% of total billed charges,$14.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.15 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.45 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.22 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.96 ,$43.63 ,
SUTURE VICRYL #1  J341H,11535,CDM,270,RC,,HCPCS,outpatient,,,$43.92 ,$15.37 ,,$23.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.14 ,80,,,percent of total billed charges,80% of total billed charges,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.56 ,$41.72 ,
SUTURE VICRYL 0  J329H,11539,CDM,270,RC,,HCPCS,outpatient,,,$10.66 ,$3.73 ,,$5.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.00 ,75,,,percent of total billed charges,75% of total billed charges,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.53 ,80,,,percent of total billed charges,80% of total billed charges,$3.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.73 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.46 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.06 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.08 ,$10.13 ,
SUTURE VICRYL 0  J287G,11846,CDM,270,RC,,HCPCS,outpatient,,,$60.93 ,$21.33 ,,$32.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.70 ,75,,,percent of total billed charges,75% of total billed charges,$45.70 ,75,,,percent of total billed charges,75% of total billed charges,$45.70 ,75,,,percent of total billed charges,75% of total billed charges,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.74 ,80,,,percent of total billed charges,80% of total billed charges,$19.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.88 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.89 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.66 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.88 ,$57.88 ,
SUTURE VICRYL 0  J945H,11543,CDM,270,RC,,HCPCS,outpatient,,,$45.35 ,$15.87 ,,$24.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.31 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.01 ,75,,,percent of total billed charges,75% of total billed charges,$34.01 ,75,,,percent of total billed charges,75% of total billed charges,$34.01 ,75,,,percent of total billed charges,75% of total billed charges,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.28 ,80,,,percent of total billed charges,80% of total billed charges,$14.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.75 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.82 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.84 ,$43.08 ,
SUTURE VICRYL 0  J958H,11841,CDM,270,RC,,HCPCS,outpatient,,,$46.01 ,$16.10 ,,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$34.51 ,75,,,percent of total billed charges,75% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.81 ,80,,,percent of total billed charges,80% of total billed charges,$14.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.21 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.41 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.51 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.11 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.15 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.97 ,$43.71 ,
SUTURE VICRYL 0  J260H,11845,CDM,270,RC,,HCPCS,outpatient,,,$42.35 ,$14.82 ,,$22.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.76 ,75,,,percent of total billed charges,75% of total billed charges,$31.76 ,75,,,percent of total billed charges,75% of total billed charges,$31.76 ,75,,,percent of total billed charges,75% of total billed charges,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.88 ,80,,,percent of total billed charges,80% of total billed charges,$13.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.82 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.26 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.88 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.42 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.26 ,$40.23 ,
SUTURE VICRYL 0  J340H,11533,CDM,270,RC,,HCPCS,outpatient,,,$42.76 ,$14.97 ,,$22.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.07 ,75,,,percent of total billed charges,75% of total billed charges,$32.07 ,75,,,percent of total billed charges,75% of total billed charges,$32.07 ,75,,,percent of total billed charges,75% of total billed charges,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.21 ,80,,,percent of total billed charges,80% of total billed charges,$13.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.93 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.34 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.48 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.62 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.07 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.34 ,$40.62 ,
SUTURE VICRYL 0  JJ31G,11910,CDM,270,RC,,HCPCS,outpatient,,,$256.82 ,$89.89 ,,$137.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$137.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$192.62 ,75,,,percent of total billed charges,75% of total billed charges,$192.62 ,75,,,percent of total billed charges,75% of total billed charges,$192.62 ,75,,,percent of total billed charges,75% of total billed charges,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$205.46 ,80,,,percent of total billed charges,80% of total billed charges,$81.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$89.89 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$179.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$179.77 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$197.75 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.41 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$79.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$231.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$51.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$243.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.84 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$192.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$51.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$218.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.08 ,$243.98 ,
SUTURE VICRYL 0  VCP334H,12793,CDM,270,RC,,HCPCS,outpatient,,,$49.62 ,$17.37 ,,$26.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.22 ,75,,,percent of total billed charges,75% of total billed charges,$37.22 ,75,,,percent of total billed charges,75% of total billed charges,$37.22 ,75,,,percent of total billed charges,75% of total billed charges,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$39.70 ,80,,,percent of total billed charges,80% of total billed charges,$15.69 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$44.66 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.18 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.68 ,$47.14 ,
SUTURE VICRYL 0  VCP270H,12794,CDM,270,RC,,HCPCS,outpatient,,,$50.57 ,$17.70 ,,$27.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.93 ,75,,,percent of total billed charges,75% of total billed charges,$37.93 ,75,,,percent of total billed charges,75% of total billed charges,$37.93 ,75,,,percent of total billed charges,75% of total billed charges,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.46 ,80,,,percent of total billed charges,80% of total billed charges,$15.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.68 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$48.04 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.46 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.98 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.86 ,$48.04 ,
SUTURE VICRYL 0 (J603H),12527,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SUTURE VICRYL 0 EJ10G,12689,CDM,270,RC,,HCPCS,outpatient,,,$74.46 ,$26.06 ,,$39.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.85 ,75,,,percent of total billed charges,75% of total billed charges,$55.85 ,75,,,percent of total billed charges,75% of total billed charges,$55.85 ,75,,,percent of total billed charges,75% of total billed charges,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.57 ,80,,,percent of total billed charges,80% of total billed charges,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.74 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.57 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.29 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.52 ,$70.74 ,
SUTURE VICRYL 0 J946H,11857,CDM,270,RC,,HCPCS,outpatient,,,$12.06 ,$4.22 ,,$6.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.05 ,75,,,percent of total billed charges,75% of total billed charges,$9.05 ,75,,,percent of total billed charges,75% of total billed charges,$9.05 ,75,,,percent of total billed charges,75% of total billed charges,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.65 ,80,,,percent of total billed charges,80% of total billed charges,$3.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.22 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.44 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$10.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.05 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.35 ,$11.46 ,
SUTURE VICRYL 1 (J371H),11529,CDM,270,RC,,HCPCS,outpatient,,,$46.75 ,$16.36 ,,$25.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.06 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.06 ,75,,,percent of total billed charges,75% of total billed charges,$35.06 ,75,,,percent of total billed charges,75% of total billed charges,$35.06 ,75,,,percent of total billed charges,75% of total billed charges,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.40 ,80,,,percent of total billed charges,80% of total billed charges,$14.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.64 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.12 ,$44.41 ,
SUTURE VICRYL 1 J765G,11284,CDM,270,RC,,HCPCS,outpatient,,,$259.08 ,$90.68 ,,$138.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$138.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$194.31 ,75,,,percent of total billed charges,75% of total billed charges,$194.31 ,75,,,percent of total billed charges,75% of total billed charges,$194.31 ,75,,,percent of total billed charges,75% of total billed charges,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.26 ,80,,,percent of total billed charges,80% of total billed charges,$81.92 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$90.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$207.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$181.36 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$199.49 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$80.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$233.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$246.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$207.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$194.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$194.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$194.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.02 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$220.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.52 ,$246.13 ,
SUTURE VICRYL 2-0  J269H,11797,CDM,270,RC,,HCPCS,outpatient,,,$44.97 ,$15.74 ,,$24.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$33.73 ,75,,,percent of total billed charges,75% of total billed charges,$33.73 ,75,,,percent of total billed charges,75% of total billed charges,$33.73 ,75,,,percent of total billed charges,75% of total billed charges,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.98 ,80,,,percent of total billed charges,80% of total billed charges,$14.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$34.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.08 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.47 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$33.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.77 ,$42.72 ,
SUTURE VICRYL 2-0  J285G,11837,CDM,270,RC,,HCPCS,outpatient,,,$61.03 ,$21.36 ,,$32.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.77 ,75,,,percent of total billed charges,75% of total billed charges,$45.77 ,75,,,percent of total billed charges,75% of total billed charges,$45.77 ,75,,,percent of total billed charges,75% of total billed charges,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.82 ,80,,,percent of total billed charges,80% of total billed charges,$19.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.72 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.11 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.25 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.88 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.90 ,$57.98 ,
SUTURE VICRYL 2-0  J339H,11681,CDM,270,RC,,HCPCS,outpatient,,,$42.16 ,$14.76 ,,$22.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$31.62 ,75,,,percent of total billed charges,75% of total billed charges,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.73 ,80,,,percent of total billed charges,80% of total billed charges,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.22 ,$40.05 ,
SUTURE VICRYL 2-0  J333H,11534,CDM,270,RC,,HCPCS,outpatient,,,$43.14 ,$15.10 ,,$23.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.36 ,75,,,percent of total billed charges,75% of total billed charges,$32.36 ,75,,,percent of total billed charges,75% of total billed charges,$32.36 ,75,,,percent of total billed charges,75% of total billed charges,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.51 ,80,,,percent of total billed charges,80% of total billed charges,$13.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.41 ,$40.98 ,
SUTURE VICRYL 2-0  JJ42G,11911,CDM,270,RC,,HCPCS,outpatient,,,$247.50 ,$86.63 ,,$132.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.63 ,75,,,percent of total billed charges,75% of total billed charges,$185.63 ,75,,,percent of total billed charges,75% of total billed charges,$185.63 ,75,,,percent of total billed charges,75% of total billed charges,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$198.00 ,80,,,percent of total billed charges,80% of total billed charges,$78.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$198.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$173.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$190.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$222.75 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$235.13 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$230.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$185.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$210.38 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.26 ,$235.13 ,
SUTURE VICRYL 2-0 J317H,12417,CDM,270,RC,,HCPCS,outpatient,,,$42.17 ,$14.76 ,,$22.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.63 ,75,,,percent of total billed charges,75% of total billed charges,$31.63 ,75,,,percent of total billed charges,75% of total billed charges,$31.63 ,75,,,percent of total billed charges,75% of total billed charges,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.74 ,80,,,percent of total billed charges,80% of total billed charges,$13.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.76 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.22 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.63 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.84 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.22 ,$40.06 ,
SUTURE VICRYL 3-0 (J416H),12561,CDM,270,RC,,HCPCS,outpatient,,,$10.26 ,$3.59 ,,$5.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.70 ,75,,,percent of total billed charges,75% of total billed charges,$7.70 ,75,,,percent of total billed charges,75% of total billed charges,$7.70 ,75,,,percent of total billed charges,75% of total billed charges,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.21 ,80,,,percent of total billed charges,80% of total billed charges,$3.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.59 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.18 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.54 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.70 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.72 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.00 ,$9.75 ,
SUTURE VICRYL 3-0  J285G,11836,CDM,270,RC,,HCPCS,outpatient,,,$59.89 ,$20.96 ,,$32.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.10 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$44.92 ,75,,,percent of total billed charges,75% of total billed charges,$44.92 ,75,,,percent of total billed charges,75% of total billed charges,$44.92 ,75,,,percent of total billed charges,75% of total billed charges,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.91 ,80,,,percent of total billed charges,80% of total billed charges,$18.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$20.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$47.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.57 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$53.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$56.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.91 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$11.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.70 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$44.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$44.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$50.91 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.68 ,$56.90 ,
SUTURE VICRYL 3-0  J956G,11838,CDM,270,RC,,HCPCS,outpatient,,,$45.50 ,$15.93 ,,$24.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$34.13 ,75,,,percent of total billed charges,75% of total billed charges,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.40 ,80,,,percent of total billed charges,80% of total billed charges,$14.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.85 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.04 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$40.95 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$43.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$38.68 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.05 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.87 ,$43.23 ,
SUTURE VICRYL 3-0  J316,11839,CDM,270,RC,,HCPCS,outpatient,,,$42.28 ,$14.80 ,,$22.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.82 ,80,,,percent of total billed charges,80% of total billed charges,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.24 ,$40.17 ,
SUTURE VICRYL 3-0  J258H,11844,CDM,270,RC,,HCPCS,outpatient,,,$42.28 ,$14.80 ,,$22.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.66 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$31.71 ,75,,,percent of total billed charges,75% of total billed charges,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.82 ,80,,,percent of total billed charges,80% of total billed charges,$13.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$38.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.17 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.32 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.24 ,$40.17 ,
SUTURE VICRYL 3-0  J215H,11840,CDM,270,RC,,HCPCS,outpatient,,,$47.59 ,$16.66 ,,$25.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$25.51 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.69 ,75,,,percent of total billed charges,75% of total billed charges,$35.69 ,75,,,percent of total billed charges,75% of total billed charges,$35.69 ,75,,,percent of total billed charges,75% of total billed charges,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$38.07 ,80,,,percent of total billed charges,80% of total billed charges,$15.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$38.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.64 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$42.83 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$45.21 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.07 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.26 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$35.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.69 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$40.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.28 ,$45.21 ,
SUTURE VICRYL 3-0  J646H,11842,CDM,270,RC,,HCPCS,outpatient,,,$67.10 ,$23.49 ,,$35.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$35.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$50.33 ,75,,,percent of total billed charges,75% of total billed charges,$50.33 ,75,,,percent of total billed charges,75% of total billed charges,$50.33 ,75,,,percent of total billed charges,75% of total billed charges,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$53.68 ,80,,,percent of total billed charges,80% of total billed charges,$21.22 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$23.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$53.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.97 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$51.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.01 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$20.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$60.39 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$13.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.68 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$62.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$50.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$50.33 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.08 ,$63.75 ,
SUTURE VICRYL 3-0  J442H,11798,CDM,270,RC,,HCPCS,outpatient,,,$60.48 ,$21.17 ,,$32.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.36 ,75,,,percent of total billed charges,75% of total billed charges,$45.36 ,75,,,percent of total billed charges,75% of total billed charges,$45.36 ,75,,,percent of total billed charges,75% of total billed charges,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.38 ,80,,,percent of total billed charges,80% of total billed charges,$19.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.17 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.34 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.79 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.75 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.43 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.46 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.36 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.79 ,$57.46 ,
SUTURE VICRYL 3-0  K423H,11537,CDM,270,RC,,HCPCS,outpatient,,,$60.64 ,$21.22 ,,$32.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.48 ,75,,,percent of total billed charges,75% of total billed charges,$45.48 ,75,,,percent of total billed charges,75% of total billed charges,$45.48 ,75,,,percent of total billed charges,75% of total billed charges,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$48.51 ,80,,,percent of total billed charges,80% of total billed charges,$19.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$21.22 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$42.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$46.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.82 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$18.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$54.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$12.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$57.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.51 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$45.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.54 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.82 ,$57.61 ,
SUTURE VICRYL 3-0 J864D,12562,CDM,270,RC,,HCPCS,outpatient,,,$261.41 ,$91.49 ,,$140.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$140.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$196.06 ,75,,,percent of total billed charges,75% of total billed charges,$196.06 ,75,,,percent of total billed charges,75% of total billed charges,$196.06 ,75,,,percent of total billed charges,75% of total billed charges,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$209.13 ,80,,,percent of total billed charges,80% of total billed charges,$82.66 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$91.49 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$182.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$182.99 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$201.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$81.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$235.27 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$52.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$248.34 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.13 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$51.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$196.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$196.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$196.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$222.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$50.97 ,$248.34 ,
SUTURE VICRYL 4-0 P-3 UNDYED COATED,30051,CDM,270,RC,,HCPCS,outpatient,,,$17.45 ,$6.11 ,,$9.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.09 ,75,,,percent of total billed charges,75% of total billed charges,$13.09 ,75,,,percent of total billed charges,75% of total billed charges,$13.09 ,75,,,percent of total billed charges,75% of total billed charges,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.96 ,80,,,percent of total billed charges,80% of total billed charges,$5.52 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$15.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.58 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.96 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.40 ,$16.58 ,
SUTURE VICRYL 4-0  J441h,11659,CDM,270,RC,,HCPCS,outpatient,,,$28.03 ,$9.81 ,,$15.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$15.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.02 ,75,,,percent of total billed charges,75% of total billed charges,$21.02 ,75,,,percent of total billed charges,75% of total billed charges,$21.02 ,75,,,percent of total billed charges,75% of total billed charges,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.42 ,80,,,percent of total billed charges,80% of total billed charges,$8.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.81 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.58 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.78 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$25.23 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.42 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.07 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$21.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$23.83 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.58 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.47 ,$26.63 ,
SUTURE VICRYL 4-0 (J496G),111530,CDM,270,RC,,HCPCS,outpatient,,,$101.02 ,$35.36 ,,$54.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.77 ,75,,,percent of total billed charges,75% of total billed charges,$75.77 ,75,,,percent of total billed charges,75% of total billed charges,$75.77 ,75,,,percent of total billed charges,75% of total billed charges,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$80.82 ,80,,,percent of total billed charges,80% of total billed charges,$31.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$80.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$70.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.63 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.32 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$90.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.97 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$75.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$75.77 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$85.87 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.70 ,$95.97 ,
SUTURE VICRYL 4-0  464G,11821,CDM,270,RC,,HCPCS,outpatient,,,$110.94 ,$38.83 ,,$59.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.75 ,80,,,percent of total billed charges,80% of total billed charges,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$105.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.63 ,$105.39 ,
SUTURE VICRYL 4-0  J823G,12563,CDM,270,RC,,HCPCS,outpatient,,,$110.94 ,$38.83 ,,$59.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.46 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$83.21 ,75,,,percent of total billed charges,75% of total billed charges,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$88.75 ,80,,,percent of total billed charges,80% of total billed charges,$35.08 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$77.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.42 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.73 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.74 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$99.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$105.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.75 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.21 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.63 ,$105.39 ,
SUTURE VICRYL 4-0  J415H,11536,CDM,270,RC,,HCPCS,outpatient,,,$43.47 ,$15.21 ,,$23.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.60 ,75,,,percent of total billed charges,75% of total billed charges,$32.60 ,75,,,percent of total billed charges,75% of total billed charges,$32.60 ,75,,,percent of total billed charges,75% of total billed charges,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.78 ,80,,,percent of total billed charges,80% of total billed charges,$13.75 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.12 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.60 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.73 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.48 ,$41.30 ,
SUTURE VICRYL 4-0  J310h,11647,CDM,270,RC,,HCPCS,outpatient,,,$43.92 ,$15.37 ,,$23.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$32.94 ,75,,,percent of total billed charges,75% of total billed charges,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.14 ,80,,,percent of total billed charges,80% of total billed charges,$13.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$15.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$33.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$13.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$13.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$13.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$39.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$41.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$32.94 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.56 ,$41.72 ,
SUTURE VICRYL 5-0 J495G,11532,CDM,270,RC,,HCPCS,outpatient,,,$102.07 ,$35.72 ,,$54.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.55 ,75,,,percent of total billed charges,75% of total billed charges,$76.55 ,75,,,percent of total billed charges,75% of total billed charges,$76.55 ,75,,,percent of total billed charges,75% of total billed charges,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.66 ,80,,,percent of total billed charges,80% of total billed charges,$32.27 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.72 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$91.86 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.97 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$86.76 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.90 ,$96.97 ,
SUTURE VICRYL 5-0  J493G,11678,CDM,270,RC,,HCPCS,outpatient,,,$112.00 ,$39.20 ,,$60.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$84.00 ,75,,,percent of total billed charges,75% of total billed charges,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.60 ,80,,,percent of total billed charges,80% of total billed charges,$35.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.84 ,$106.40 ,
SUTURE VICRYL 5-0  J463G,11820,CDM,270,RC,,HCPCS,outpatient,,,$112.01 ,$39.20 ,,$60.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$84.01 ,75,,,percent of total billed charges,75% of total billed charges,$84.01 ,75,,,percent of total billed charges,75% of total billed charges,$84.01 ,75,,,percent of total billed charges,75% of total billed charges,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.61 ,80,,,percent of total billed charges,80% of total billed charges,$35.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.20 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.41 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$86.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$84.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$95.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.84 ,$106.41 ,
SUTURE VICRYL 5-0  J43h,11650,CDM,270,RC,,HCPCS,outpatient,,,$54.15 ,$18.95 ,,$29.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$40.61 ,75,,,percent of total billed charges,75% of total billed charges,$40.61 ,75,,,percent of total billed charges,75% of total billed charges,$40.61 ,75,,,percent of total billed charges,75% of total billed charges,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.32 ,80,,,percent of total billed charges,80% of total billed charges,$17.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$37.91 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$41.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.95 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.79 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$48.74 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$51.44 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.32 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$50.36 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$40.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.61 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$46.03 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.56 ,$51.44 ,
SUTURE VICRYL 6-0  J489G,11805,CDM,270,RC,,HCPCS,outpatient,,,$113.26 ,$39.64 ,,$60.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.71 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$84.95 ,75,,,percent of total billed charges,75% of total billed charges,$84.95 ,75,,,percent of total billed charges,75% of total billed charges,$84.95 ,75,,,percent of total billed charges,75% of total billed charges,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.61 ,80,,,percent of total billed charges,80% of total billed charges,$35.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.64 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$87.21 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.46 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.11 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$101.93 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.33 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$84.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$96.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.09 ,$107.60 ,
SUTURE VICRYL 6-0  F544G,11680,CDM,270,RC,,HCPCS,outpatient,,,$306.05 ,$107.12 ,,$164.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$164.04 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$229.54 ,75,,,percent of total billed charges,75% of total billed charges,$229.54 ,75,,,percent of total billed charges,75% of total billed charges,$229.54 ,75,,,percent of total billed charges,75% of total billed charges,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$244.84 ,80,,,percent of total billed charges,80% of total billed charges,$96.77 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$107.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$244.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$214.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$235.66 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$95.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$95.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$95.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.68 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$94.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$275.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$61.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$290.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$60.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.63 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$229.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$229.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$229.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$61.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$260.14 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$60.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.68 ,$290.75 ,
SUTURE VICRYL 7-0,11662,CDM,270,RC,,HCPCS,outpatient,,,$116.05 ,$40.62 ,,$62.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.04 ,75,,,percent of total billed charges,75% of total billed charges,$87.04 ,75,,,percent of total billed charges,75% of total billed charges,$87.04 ,75,,,percent of total billed charges,75% of total billed charges,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$92.84 ,80,,,percent of total billed charges,80% of total billed charges,$36.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$89.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$35.98 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$104.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$110.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.08 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.63 ,$110.25 ,
SUTURE VICRYL 8-0,12658,CDM,270,RC,,HCPCS,outpatient,,,$326.07 ,$114.12 ,,$174.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$174.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$244.55 ,75,,,percent of total billed charges,75% of total billed charges,$244.55 ,75,,,percent of total billed charges,75% of total billed charges,$244.55 ,75,,,percent of total billed charges,75% of total billed charges,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$260.86 ,80,,,percent of total billed charges,80% of total billed charges,$103.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$114.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$260.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$228.25 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$251.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$101.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$293.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$65.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$309.77 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$260.86 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$64.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.25 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$244.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$244.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$65.47 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$277.16 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.58 ,$309.77 ,
SUTURE VICRYL J356H,12633,CDM,270,RC,,HCPCS,outpatient,,,$46.42 ,$16.25 ,,$24.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$34.82 ,75,,,percent of total billed charges,75% of total billed charges,$34.82 ,75,,,percent of total billed charges,75% of total billed charges,$34.82 ,75,,,percent of total billed charges,75% of total billed charges,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.14 ,80,,,percent of total billed charges,80% of total billed charges,$14.68 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$16.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$32.49 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.74 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$14.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$41.78 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$9.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.17 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$34.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.82 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.05 ,$44.10 ,
SYRINGE BLUE BULB,11249,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
SYRINGE IRRG 2 PEC BULB 60CC,90460,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
Shiley  inner cannula #4,30092,CDM,270,RC,,HCPCS,outpatient,,,$39.91 ,$13.97 ,,$21.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.39 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.93 ,75,,,percent of total billed charges,75% of total billed charges,$29.93 ,75,,,percent of total billed charges,75% of total billed charges,$29.93 ,75,,,percent of total billed charges,75% of total billed charges,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.93 ,80,,,percent of total billed charges,80% of total billed charges,$12.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$35.92 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.91 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$29.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.93 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.94 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.78 ,$37.91 ,
Sling U Shaped w/hs Large,30162,CDM,270,RC,,HCPCS,outpatient,,,$185.83 ,$65.04 ,,$99.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.37 ,75,,,percent of total billed charges,75% of total billed charges,$139.37 ,75,,,percent of total billed charges,75% of total billed charges,$139.37 ,75,,,percent of total billed charges,75% of total billed charges,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.66 ,80,,,percent of total billed charges,80% of total billed charges,$58.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$143.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.19 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$167.25 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$176.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.37 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.24 ,$176.54 ,
Sling U shaped w/hs,30161,CDM,270,RC,,HCPCS,outpatient,,,$204.14 ,$71.45 ,,$109.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$109.42 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$153.11 ,75,,,percent of total billed charges,75% of total billed charges,$153.11 ,75,,,percent of total billed charges,75% of total billed charges,$153.11 ,75,,,percent of total billed charges,75% of total billed charges,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$163.31 ,80,,,percent of total billed charges,80% of total billed charges,$64.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$71.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$163.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$142.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$157.19 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$63.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$63.28 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$183.73 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$193.93 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$163.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$153.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$153.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.99 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$173.52 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.81 ,$193.93 ,
Solidifier 2000 cc bottle (OR),20318,CDM,270,RC,,HCPCS,outpatient,,,$19.40 ,$6.79 ,,$10.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.55 ,75,,,percent of total billed charges,75% of total billed charges,$14.55 ,75,,,percent of total billed charges,75% of total billed charges,$14.55 ,75,,,percent of total billed charges,75% of total billed charges,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.52 ,80,,,percent of total billed charges,80% of total billed charges,$6.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.79 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.58 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$14.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$17.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.52 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.04 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$14.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.55 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$16.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.78 ,$18.43 ,
Statlock Cath  Device,11582,CDM,270,RC,,HCPCS,outpatient,,,$12.72 ,$4.45 ,,$6.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.82 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.54 ,75,,,percent of total billed charges,75% of total billed charges,$9.54 ,75,,,percent of total billed charges,75% of total billed charges,$9.54 ,75,,,percent of total billed charges,75% of total billed charges,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.18 ,80,,,percent of total billed charges,80% of total billed charges,$4.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.98 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.08 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.48 ,$12.08 ,
Statlock PICC Plus Device,20353,CDM,270,RC,,HCPCS,outpatient,,,$35.54 ,$12.44 ,,$19.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.05 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.66 ,75,,,percent of total billed charges,75% of total billed charges,$26.66 ,75,,,percent of total billed charges,75% of total billed charges,$26.66 ,75,,,percent of total billed charges,75% of total billed charges,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.43 ,80,,,percent of total billed charges,80% of total billed charges,$11.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.88 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.02 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$31.99 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.93 ,$33.76 ,
Stocking  Thigh Hi XL Reg,92398,CDM,270,RC,,HCPCS,outpatient,,,$38.33 ,$13.42 ,,$20.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$20.54 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$28.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.75 ,75,,,percent of total billed charges,75% of total billed charges,$28.75 ,75,,,percent of total billed charges,75% of total billed charges,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.66 ,80,,,percent of total billed charges,80% of total billed charges,$12.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.42 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.00 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.47 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.88 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$34.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$36.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$28.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$32.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.47 ,$36.41 ,
Suprapubic introducer,30130,CDM,270,RC,,HCPCS,outpatient,,,$407.06 ,$142.47 ,,$218.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$218.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$305.30 ,75,,,percent of total billed charges,75% of total billed charges,$305.30 ,75,,,percent of total billed charges,75% of total billed charges,$305.30 ,75,,,percent of total billed charges,75% of total billed charges,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$325.65 ,80,,,percent of total billed charges,80% of total billed charges,$128.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$142.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$325.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$284.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$284.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$313.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.45 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$126.19 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$366.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$81.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$386.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$325.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$80.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.57 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$305.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$305.30 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$346.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$80.96 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.38 ,$386.71 ,
Suture 1653g,11646,CDM,272,RC,,HCPCS,outpatient,,,$157.07 ,$54.97 ,,$84.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$84.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.80 ,75,,,percent of total billed charges,75% of total billed charges,$117.80 ,75,,,percent of total billed charges,75% of total billed charges,$117.80 ,75,,,percent of total billed charges,75% of total billed charges,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$125.66 ,80,,,percent of total billed charges,80% of total billed charges,$49.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$109.95 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$120.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$49.18 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.63 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$141.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$149.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$146.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$117.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.80 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.63 ,$149.22 ,
Suture Grasper,11395,CDM,270,RC,,HCPCS,outpatient,,,$226.35 ,$79.22 ,,$121.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$121.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$169.76 ,75,,,percent of total billed charges,75% of total billed charges,$169.76 ,75,,,percent of total billed charges,75% of total billed charges,$169.76 ,75,,,percent of total billed charges,75% of total billed charges,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$181.08 ,80,,,percent of total billed charges,80% of total billed charges,$71.57 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$79.22 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$181.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$158.45 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$174.29 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$70.87 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$70.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$203.72 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$45.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$215.03 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$181.08 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$45.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$169.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$169.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$169.76 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$45.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$192.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.14 ,$215.03 ,
Suture PDS Z316H 3.0,30191,CDM,270,RC,,HCPCS,outpatient,,,$74.45 ,$26.06 ,,$39.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$39.91 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.84 ,75,,,percent of total billed charges,75% of total billed charges,$55.84 ,75,,,percent of total billed charges,75% of total billed charges,$55.84 ,75,,,percent of total billed charges,75% of total billed charges,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$59.56 ,80,,,percent of total billed charges,80% of total billed charges,$23.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$26.06 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$52.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$57.33 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.52 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$23.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$67.01 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$70.73 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$55.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$55.84 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$63.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$14.52 ,$70.73 ,
T Piece In-Line NebTee w/valve,12704,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
T-POD,12677,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TAPE DURAPORE SILK 1'  1538,30061,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
"TCC 3"" Casting Noboot",20296,CDM,270,RC,,HCPCS,outpatient,,,$416.00 ,$145.60 ,,$222.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$222.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$312.00 ,75,,,percent of total billed charges,75% of total billed charges,$312.00 ,75,,,percent of total billed charges,75% of total billed charges,$312.00 ,75,,,percent of total billed charges,75% of total billed charges,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$332.80 ,80,,,percent of total billed charges,80% of total billed charges,$131.54 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$145.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$332.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$291.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$291.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$320.32 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$130.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$128.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$374.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$83.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$395.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$332.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$386.88 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$312.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$312.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.53 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$353.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.74 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.12 ,$395.20 ,
"TCC-EZ 3"" casting system w/2 reg. boots",30118,CDM,270,RC,,HCPCS,outpatient,,,$294.79 ,$103.18 ,,$158.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.01 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$221.09 ,75,,,percent of total billed charges,75% of total billed charges,$221.09 ,75,,,percent of total billed charges,75% of total billed charges,$221.09 ,75,,,percent of total billed charges,75% of total billed charges,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$235.83 ,80,,,percent of total billed charges,80% of total billed charges,$93.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$103.18 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$235.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$226.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.38 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$265.31 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.05 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$235.83 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$221.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.09 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.57 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.48 ,$280.05 ,
"TCC-EZ 4"" casting w/no boot",30119,CDM,270,RC,,HCPCS,outpatient,,,$420.00 ,$147.00 ,,$225.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$315.00 ,75,,,percent of total billed charges,75% of total billed charges,$315.00 ,75,,,percent of total billed charges,75% of total billed charges,$315.00 ,75,,,percent of total billed charges,75% of total billed charges,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$336.00 ,80,,,percent of total billed charges,80% of total billed charges,$132.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$147.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$336.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$294.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$323.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.90 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$130.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$378.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$84.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$399.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$83.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$390.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$315.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$315.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$315.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$84.34 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$357.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$81.90 ,$399.00 ,
TCC-EZ EX Large Boot,30117,CDM,270,RC,,HCPCS,outpatient,,,$366.56 ,$128.30 ,,$196.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$196.48 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$274.92 ,75,,,percent of total billed charges,75% of total billed charges,$274.92 ,75,,,percent of total billed charges,75% of total billed charges,$274.92 ,75,,,percent of total billed charges,75% of total billed charges,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$293.25 ,80,,,percent of total billed charges,80% of total billed charges,$115.91 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$128.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$293.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$256.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$256.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$282.25 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$114.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.48 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$113.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$329.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$73.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$348.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$293.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$274.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$274.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$73.61 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$311.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.48 ,$348.23 ,
TCC-EZ Large Boot,30116,CDM,270,RC,,HCPCS,outpatient,,,$349.35 ,$122.27 ,,$187.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$187.25 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$262.01 ,75,,,percent of total billed charges,75% of total billed charges,$262.01 ,75,,,percent of total billed charges,75% of total billed charges,$262.01 ,75,,,percent of total billed charges,75% of total billed charges,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$279.48 ,80,,,percent of total billed charges,80% of total billed charges,$110.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$279.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$244.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$244.55 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.12 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.30 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$314.42 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$331.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$324.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$262.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$262.01 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$296.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.12 ,$331.88 ,
"TECHFORM CASTING TAPE WHT 3""",30052,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TEGADERM CHG 4X4 3/4 1658,12484,CDM,270,RC,,HCPCS,outpatient,,,$25.33 ,$8.87 ,,$13.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$19.00 ,75,,,percent of total billed charges,75% of total billed charges,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$20.26 ,80,,,percent of total billed charges,80% of total billed charges,$8.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.87 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.73 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$19.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.94 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$22.80 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$24.06 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.56 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.09 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.53 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.04 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.94 ,$24.06 ,
TEGADERM DRESSING 4 X 4,11391,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA ADHESIVE PAD 2X3,28592,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA ADHESIVE PAD 3X4,28591,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA ISLAND DRESSING 4x5,28649,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA NON ADHERANT PAD 3 X 4,11097,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA NON ADHERANT PAD 3 X 8,11145,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TELFA NON ADHERANT PAD 2X3,12473,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
THORACENTESIS TRAY,11157,CDM,270,RC,,HCPCS,outpatient,,,$103.82 ,$36.34 ,,$55.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.87 ,75,,,percent of total billed charges,75% of total billed charges,$77.87 ,75,,,percent of total billed charges,75% of total billed charges,$77.87 ,75,,,percent of total billed charges,75% of total billed charges,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$83.06 ,80,,,percent of total billed charges,80% of total billed charges,$32.83 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$36.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$72.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$32.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$93.44 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$98.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.06 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$77.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.87 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.85 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.65 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.24 ,$98.63 ,
TONGUE BLADES NON STERILE,CDM,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
TOURNIQUET ORANGE C-A-T,CDM,CDM,250,RC,,HCPCS,outpatient,,,$626.12 ,$219.14 ,,$335.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$335.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$469.59 ,75,,,percent of total billed charges,75% of total billed charges,$469.59 ,75,,,percent of total billed charges,75% of total billed charges,$469.59 ,75,,,percent of total billed charges,75% of total billed charges,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$500.90 ,80,,,percent of total billed charges,80% of total billed charges,$197.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$219.14 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$500.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$438.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$438.28 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$482.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$196.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$194.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$563.51 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$125.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$594.81 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$500.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$124.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$582.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$469.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$469.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$469.59 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$125.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$532.20 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.54 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.09 ,$594.81 ,
TRACH CLEANING TRAY,28708,CDM,270,RC,,HCPCS,outpatient,,,$12.27 ,$4.29 ,,$6.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.20 ,75,,,percent of total billed charges,75% of total billed charges,$9.20 ,75,,,percent of total billed charges,75% of total billed charges,$9.20 ,75,,,percent of total billed charges,75% of total billed charges,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.82 ,80,,,percent of total billed charges,80% of total billed charges,$3.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.29 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.04 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$11.66 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.82 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.20 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.39 ,$11.66 ,
TRACH HI LOW CUFFED 3MM,93080,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TRACH Humidification Aquapak 728,28865,CDM,270,RC,,HCPCS,outpatient,,,$51.81 ,$18.13 ,,$27.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$38.86 ,75,,,percent of total billed charges,75% of total billed charges,$38.86 ,75,,,percent of total billed charges,75% of total billed charges,$38.86 ,75,,,percent of total billed charges,75% of total billed charges,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.45 ,80,,,percent of total billed charges,80% of total billed charges,$16.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$18.13 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$36.27 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$39.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$16.22 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$16.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$46.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$49.22 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.45 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$38.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$38.86 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$44.04 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.10 ,$49.22 ,
TRACH INTRODUCER TRAY BLUE RHINO G57707,93035,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TRACH TUBE CUFFED 9.5 MM,93096,CDM,272,RC,,HCPCS,outpatient,,,$174.61 ,$61.11 ,,$93.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.69 ,80,,,percent of total billed charges,80% of total billed charges,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.05 ,$165.88 ,
TRACH TUBE HOLDER,28709,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TRACHEAL TUBE INTRODUCER,12505,CDM,270,RC,,HCPCS,outpatient,,,$149.63 ,$52.37 ,,$80.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.22 ,75,,,percent of total billed charges,75% of total billed charges,$112.22 ,75,,,percent of total billed charges,75% of total billed charges,$112.22 ,75,,,percent of total billed charges,75% of total billed charges,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$119.70 ,80,,,percent of total billed charges,80% of total billed charges,$47.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.37 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.74 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.18 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.39 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$134.67 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.22 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.19 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.18 ,$142.15 ,
TRACHEOSTOMY MASK ADULT,12395,CDM,270,RC,,HCPCS,outpatient,,,$10.69 ,$3.74 ,,$5.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.02 ,75,,,percent of total billed charges,75% of total billed charges,$8.02 ,75,,,percent of total billed charges,75% of total billed charges,$8.02 ,75,,,percent of total billed charges,75% of total billed charges,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.55 ,80,,,percent of total billed charges,80% of total billed charges,$3.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.48 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.23 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.34 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.62 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.16 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.55 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.94 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.02 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.15 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.08 ,$10.16 ,
TRAPEASE FILTER 55CM,12637,CDM,270,RC,,HCPCS,outpatient,,,"$3,978.00 ","$1,392.30 ",,"$2,132.21 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,132.21 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,392.30 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,784.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,784.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,063.06 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$775.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,233.18 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,580.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$798.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,779.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,699.54 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$798.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$775.71 ,"$3,779.10 ",
TRAPEASE FILTER 90CM,12638,CDM,270,RC,,HCPCS,outpatient,,,"$3,978.00 ","$1,392.30 ",,"$2,132.21 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,132.21 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,257.84 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,392.30 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,784.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,784.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,063.06 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,245.51 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$775.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,233.18 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,580.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$798.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,779.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,182.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,699.54 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,983.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$798.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,381.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$791.22 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$775.71 ,"$3,779.10 ",
TROCAR 12MM BLUNT TIP,12585,CDM,270,RC,,HCPCS,outpatient,,,$660.76 ,$231.27 ,,$354.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$354.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$495.57 ,75,,,percent of total billed charges,75% of total billed charges,$495.57 ,75,,,percent of total billed charges,75% of total billed charges,$495.57 ,75,,,percent of total billed charges,75% of total billed charges,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$528.61 ,80,,,percent of total billed charges,80% of total billed charges,$208.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$231.27 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$528.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$462.53 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$508.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$206.89 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$206.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$206.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$204.84 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$594.68 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$132.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$627.72 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$528.61 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$614.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$495.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$495.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$495.57 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$132.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$561.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$128.85 ,$627.72 ,
TUBE 20 FR PEG,30122,CDM,270,RC,,HCPCS,outpatient,,,$347.52 ,$121.63 ,,$186.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$186.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$260.64 ,75,,,percent of total billed charges,75% of total billed charges,$260.64 ,75,,,percent of total billed charges,75% of total billed charges,$260.64 ,75,,,percent of total billed charges,75% of total billed charges,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$278.02 ,80,,,percent of total billed charges,80% of total billed charges,$109.89 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$121.63 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$278.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$243.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$243.26 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$267.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$107.73 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$312.77 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$69.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$330.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.02 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$323.19 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$260.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$260.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$260.64 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$295.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.77 ,$330.14 ,
TUBE BLAKEMORE 16 FR,11563,CDM,270,RC,,HCPCS,outpatient,,,$147.31 ,$51.56 ,,$78.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$78.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$110.48 ,75,,,percent of total billed charges,75% of total billed charges,$110.48 ,75,,,percent of total billed charges,75% of total billed charges,$110.48 ,75,,,percent of total billed charges,75% of total billed charges,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$117.85 ,80,,,percent of total billed charges,80% of total billed charges,$46.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$51.56 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$103.12 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$113.43 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$45.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$132.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$139.94 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$110.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$110.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.58 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$125.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.30 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.73 ,$139.94 ,
TUBE FEEDING 8 FR,93105,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TUBE GASTROSTOMY 18 FR 20CC BAL MIC,12681,CDM,270,RC,,HCPCS,outpatient,,,$116.95 ,$40.93 ,,$62.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.56 ,80,,,percent of total billed charges,80% of total billed charges,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$105.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.81 ,$111.10 ,
TUBE GASTROSTOMY 16 FR 20CC BAL MIC,11719,CDM,270,RC,,HCPCS,outpatient,,,$137.75 ,$48.21 ,,$73.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$73.83 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$103.31 ,75,,,percent of total billed charges,75% of total billed charges,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.20 ,80,,,percent of total billed charges,80% of total billed charges,$43.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$48.21 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$96.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$106.07 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.86 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$123.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$130.86 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$128.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$103.31 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.66 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$117.09 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.86 ,$130.86 ,
TUBE GASTROSTOMY 20 FR 20CC BAL MIC,12748,CDM,270,RC,,HCPCS,outpatient,,,$116.95 ,$40.93 ,,$62.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$62.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$87.71 ,75,,,percent of total billed charges,75% of total billed charges,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.56 ,80,,,percent of total billed charges,80% of total billed charges,$36.98 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$40.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$81.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$90.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$36.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$36.62 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.81 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$36.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$105.26 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$23.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.56 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.71 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$99.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.81 ,$111.10 ,
TUBE HOLDER HOLLISTER ANCHOR FAST,12818,CDM,270,RC,,HCPCS,outpatient,,,$39.53 ,$13.84 ,,$21.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$21.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$29.65 ,75,,,percent of total billed charges,75% of total billed charges,$29.65 ,75,,,percent of total billed charges,75% of total billed charges,$29.65 ,75,,,percent of total billed charges,75% of total billed charges,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$31.62 ,80,,,percent of total billed charges,80% of total billed charges,$12.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.84 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$30.44 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.71 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.25 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$35.58 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$37.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.76 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$29.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.65 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$33.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.86 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.71 ,$37.55 ,
TUBE T 10 FR,11303,CDM,270,RC,,HCPCS,outpatient,,,$102.74 ,$35.96 ,,$55.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$55.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.06 ,75,,,percent of total billed charges,75% of total billed charges,$77.06 ,75,,,percent of total billed charges,75% of total billed charges,$77.06 ,75,,,percent of total billed charges,75% of total billed charges,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$82.19 ,80,,,percent of total billed charges,80% of total billed charges,$32.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.96 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$79.11 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$92.47 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.19 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$77.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.06 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.33 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.43 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.03 ,$97.60 ,
TUBE T 12 FR,12758,CDM,270,RC,,HCPCS,outpatient,,,$108.72 ,$38.05 ,,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.20 ,$103.28 ,
TUBE T 14 FR,12759,CDM,270,RC,,HCPCS,outpatient,,,$108.72 ,$38.05 ,,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.20 ,$103.28 ,
TUBE T 16 FR,12760,CDM,270,RC,,HCPCS,outpatient,,,$108.72 ,$38.05 ,,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.20 ,$103.28 ,
TUBE T 22 FR,12761,CDM,270,RC,,HCPCS,outpatient,,,$108.72 ,$38.05 ,,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.20 ,$103.28 ,
TUBE T 24 FR,12762,CDM,270,RC,,HCPCS,outpatient,,,$108.72 ,$38.05 ,,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$81.54 ,75,,,percent of total billed charges,75% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges,$34.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$83.71 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.04 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$97.85 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$103.28 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.98 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$81.54 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$21.83 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.41 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.62 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.20 ,$103.28 ,
TUBE TRACH 8CN85H / 8DCT,93038,CDM,272,RC,,HCPCS,outpatient,,,$174.71 ,$61.15 ,,$93.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$131.03 ,75,,,percent of total billed charges,75% of total billed charges,$131.03 ,75,,,percent of total billed charges,75% of total billed charges,$131.03 ,75,,,percent of total billed charges,75% of total billed charges,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.77 ,80,,,percent of total billed charges,80% of total billed charges,$55.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.24 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.97 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.77 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$131.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.03 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.75 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.07 ,$165.97 ,
TUBE TRACH CANNULA SZ 7 - 7SCT,93039,CDM,272,RC,,HCPCS,outpatient,,,$109.57 ,$38.35 ,,$58.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$58.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$82.18 ,75,,,percent of total billed charges,75% of total billed charges,$82.18 ,75,,,percent of total billed charges,75% of total billed charges,$82.18 ,75,,,percent of total billed charges,75% of total billed charges,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$87.66 ,80,,,percent of total billed charges,80% of total billed charges,$34.65 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$38.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$76.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.31 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$33.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$98.61 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$104.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.66 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$21.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$82.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$82.18 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$93.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.37 ,$104.09 ,
TUBE TRACH CUFFED SZ 8 8LPC,93065,CDM,272,RC,,HCPCS,outpatient,,,$181.50 ,$63.53 ,,$97.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$145.20 ,80,,,percent of total billed charges,80% of total billed charges,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$163.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$172.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.39 ,$172.43 ,
TUBE TRACH CUFFED FENESTRATED SZ 8 8DFEN,93066,CDM,272,RC,,HCPCS,outpatient,,,$140.32 ,$49.11 ,,$75.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.24 ,75,,,percent of total billed charges,75% of total billed charges,$105.24 ,75,,,percent of total billed charges,75% of total billed charges,$105.24 ,75,,,percent of total billed charges,75% of total billed charges,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.26 ,80,,,percent of total billed charges,80% of total billed charges,$44.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.22 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.94 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.26 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.24 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.18 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.36 ,$133.30 ,
TUBE TRACH CUFFED FENESTRATED SZ 6 6FEN,93067,CDM,272,RC,,HCPCS,outpatient,,,$181.50 ,$63.53 ,,$97.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$97.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$136.13 ,75,,,percent of total billed charges,75% of total billed charges,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$145.20 ,80,,,percent of total billed charges,80% of total billed charges,$57.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$63.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$145.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.05 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$139.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.39 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$56.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$163.35 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$36.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$172.43 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.80 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$136.13 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$36.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$154.28 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.39 ,$172.43 ,
TUBE TRACH CUFFED 7.0 5CN70H,93036,CDM,272,RC,,HCPCS,outpatient,,,$174.61 ,$61.11 ,,$93.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$130.96 ,75,,,percent of total billed charges,75% of total billed charges,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.69 ,80,,,percent of total billed charges,80% of total billed charges,$55.21 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$61.11 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$122.23 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$134.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$54.13 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$157.15 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$35.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.69 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.39 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.96 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$35.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.05 ,$165.88 ,
TUBULAR NET BANDAGE SZ 6,30057,CDM,270,RC,,HCPCS,outpatient,,,$79.29 ,$27.75 ,,$42.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.47 ,75,,,percent of total billed charges,75% of total billed charges,$59.47 ,75,,,percent of total billed charges,75% of total billed charges,$59.47 ,75,,,percent of total billed charges,75% of total billed charges,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$63.43 ,80,,,percent of total billed charges,80% of total billed charges,$25.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$27.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$55.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.05 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.58 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$71.36 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$75.33 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.43 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$73.74 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$59.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$15.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$67.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.77 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.46 ,$75.33 ,
TUR BLADDER IRRG. Y TYPE,11313,CDM,270,RC,,HCPCS,outpatient,,,$136.05 ,$47.62 ,,$72.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$102.04 ,75,,,percent of total billed charges,75% of total billed charges,$102.04 ,75,,,percent of total billed charges,75% of total billed charges,$102.04 ,75,,,percent of total billed charges,75% of total billed charges,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$108.84 ,80,,,percent of total billed charges,80% of total billed charges,$43.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$47.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$95.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$104.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$42.18 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$122.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$27.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$129.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.84 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$126.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$102.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$115.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.53 ,$129.25 ,
TWIN PACK CANNULA,23051,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
TheraSkin per cm sq,28833,CDM,636,RC,Q4121,HCPCS,both,,,"$7,067.78 ","$2,473.72 ",,"$3,788.33 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,788.33 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,654.22 ",80,,,percent of total billed charges,80% of total billed charges,"$2,234.83 ",31.62,,,percent of total billed charges,31.62% of total billed charges,$43.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,654.22 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,947.45 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,947.45 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,442.19 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,212.92 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.86 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,"$2,191.01 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$6,361.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,"$6,714.39 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,654.22 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,573.04 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,300.84 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.12 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,"$6,007.61 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$41.86 ,"$6,714.39 ",
Therion 18mm Round,20295,CDM,270,RC,,HCPCS,outpatient,,,"$1,590.00 ",$556.50 ,,$852.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$852.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges,$502.76 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$556.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,113.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,113.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,224.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$497.83 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$310.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$492.90 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,431.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$319.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,510.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,272.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,478.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,192.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$319.27 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,351.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$310.05 ,"$1,510.50 ",
Therion 2 cm x 3 cm,20294,CDM,272,RC,,HCPCS,outpatient,,,"$2,985.00 ","$1,044.75 ",,"$1,599.96 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,599.96 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,388.00 ",80,,,percent of total billed charges,80% of total billed charges,$943.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,044.75 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,388.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,089.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,089.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,298.45 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$934.60 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$582.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$925.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,686.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$599.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,835.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,388.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$593.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,776.05 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,238.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$599.39 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,537.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$593.72 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$582.08 ,"$2,835.75 ",
Trach Speaking Valve (shiley),20314,CDM,270,RC,,HCPCS,outpatient,,,$111.67 ,$39.08 ,,$59.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$59.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.75 ,75,,,percent of total billed charges,75% of total billed charges,$83.75 ,75,,,percent of total billed charges,75% of total billed charges,$83.75 ,75,,,percent of total billed charges,75% of total billed charges,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$89.34 ,80,,,percent of total billed charges,80% of total billed charges,$35.31 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$39.08 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.17 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$85.99 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$34.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$34.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$34.96 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.78 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$34.62 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$100.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$22.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$106.09 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.34 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$83.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$83.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$94.92 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.78 ,$106.09 ,
Trach care kit,7063,CDM,270,RC,,HCPCS,outpatient,,,$33.00 ,$11.55 ,,$17.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.69 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$24.75 ,75,,,percent of total billed charges,75% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.40 ,80,,,percent of total billed charges,80% of total billed charges,$10.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.41 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.44 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$10.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$29.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.69 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.44 ,$31.35 ,
Trach collar,7064,CDM,270,RC,,HCPCS,outpatient,,,$11.00 ,$3.85 ,,$5.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.25 ,75,,,percent of total billed charges,75% of total billed charges,$8.25 ,75,,,percent of total billed charges,75% of total billed charges,$8.25 ,75,,,percent of total billed charges,75% of total billed charges,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.80 ,80,,,percent of total billed charges,80% of total billed charges,$3.48 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.47 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$8.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.19 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.15 ,$10.45 ,
UNDERPADS,12230,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
UNIHEART NEBULIZER,28898,CDM,270,RC,,HCPCS,outpatient,,,$32.16 ,$11.26 ,,$17.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$24.12 ,75,,,percent of total billed charges,75% of total billed charges,$24.12 ,75,,,percent of total billed charges,75% of total billed charges,$24.12 ,75,,,percent of total billed charges,75% of total billed charges,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.73 ,80,,,percent of total billed charges,80% of total billed charges,$10.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$11.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$22.51 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.76 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.94 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.91 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$24.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.46 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$27.34 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.40 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.27 ,$30.55 ,
UNIVERSAL RIB BELT FEMALE,11111,CDM,270,RC,,HCPCS,outpatient,,,$22.31 ,$7.81 ,,$11.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.96 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.73 ,75,,,percent of total billed charges,75% of total billed charges,$16.73 ,75,,,percent of total billed charges,75% of total billed charges,$16.73 ,75,,,percent of total billed charges,75% of total billed charges,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$17.85 ,80,,,percent of total billed charges,80% of total billed charges,$7.05 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.81 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$17.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.62 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.18 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$6.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.35 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$6.92 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.08 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$17.85 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.75 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$16.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.73 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$18.96 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.35 ,$21.19 ,
UNIVERSAL RIB BELT MALE,12380,CDM,270,RC,,HCPCS,outpatient,,,$24.10 ,$8.44 ,,$12.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$18.08 ,75,,,percent of total billed charges,75% of total billed charges,$18.08 ,75,,,percent of total billed charges,75% of total billed charges,$18.08 ,75,,,percent of total billed charges,75% of total billed charges,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$19.28 ,80,,,percent of total billed charges,80% of total billed charges,$7.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.44 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.56 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.55 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.47 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$21.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.28 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.41 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$18.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.84 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$20.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.79 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.70 ,$22.90 ,
UNIVERSAL SLEEVE 12MM/100M,12547,CDM,270,RC,,HCPCS,outpatient,,,$84.00 ,$29.40 ,,$45.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$45.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$63.00 ,75,,,percent of total billed charges,75% of total billed charges,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$67.20 ,80,,,percent of total billed charges,80% of total billed charges,$26.56 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$29.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$67.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$58.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$64.68 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.38 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$26.04 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$75.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.12 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.87 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$71.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.71 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$16.38 ,$79.80 ,
UNIVERSAL SLEEVE 5MM/100M,12546,CDM,270,RC,,HCPCS,outpatient,,,$140.15 ,$49.05 ,,$75.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$75.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$105.11 ,75,,,percent of total billed charges,75% of total billed charges,$105.11 ,75,,,percent of total billed charges,75% of total billed charges,$105.11 ,75,,,percent of total billed charges,75% of total billed charges,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$112.12 ,80,,,percent of total billed charges,80% of total billed charges,$44.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$49.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$112.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$98.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$98.11 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$107.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$43.88 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$43.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$126.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$133.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$112.12 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$27.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$105.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$105.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.14 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$119.13 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.88 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$27.33 ,$133.14 ,
"UNNA BOOT 4"" ZINC OXIDE W CALAMINE",11076,CDM,270,RC,,HCPCS,outpatient,,,$31.19 ,$10.92 ,,$16.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$23.39 ,75,,,percent of total billed charges,75% of total billed charges,$23.39 ,75,,,percent of total billed charges,75% of total billed charges,$23.39 ,75,,,percent of total billed charges,75% of total billed charges,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$24.95 ,80,,,percent of total billed charges,80% of total billed charges,$9.86 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.92 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$24.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$21.83 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$24.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.67 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$28.07 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$29.63 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.95 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$6.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.01 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$23.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$23.39 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.26 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$26.51 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.08 ,$29.63 ,
UPDRAFT NEBULIZER W/ TUBING,11625,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
URETHAL CATH TRAY 14 FR,11050,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
URINE DRAIN BAG,11061,CDM,270,RC,,HCPCS,outpatient,,,$12.88 ,$4.51 ,,$6.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$6.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.66 ,75,,,percent of total billed charges,75% of total billed charges,$9.66 ,75,,,percent of total billed charges,75% of total billed charges,$9.66 ,75,,,percent of total billed charges,75% of total billed charges,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$10.30 ,80,,,percent of total billed charges,80% of total billed charges,$4.07 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$4.51 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$9.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.51 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.99 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$11.59 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.24 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.30 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.98 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$9.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$9.66 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$10.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.51 ,$12.24 ,
URINE METER,11161,CDM,272,RC,,HCPCS,outpatient,,,$29.90 ,$10.47 ,,$16.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$16.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.43 ,75,,,percent of total billed charges,75% of total billed charges,$22.43 ,75,,,percent of total billed charges,75% of total billed charges,$22.43 ,75,,,percent of total billed charges,75% of total billed charges,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$23.92 ,80,,,percent of total billed charges,80% of total billed charges,$9.45 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$10.47 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$23.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.93 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$23.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$9.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$9.27 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$26.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$6.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$28.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.92 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$27.81 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$22.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$22.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$6.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.83 ,$28.41 ,
"Unna Boot w/Zince 4""",30149,CDM,270,RC,,HCPCS,outpatient,,,$23.31 ,$8.16 ,,$12.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.49 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.48 ,75,,,percent of total billed charges,75% of total billed charges,$17.48 ,75,,,percent of total billed charges,75% of total billed charges,$17.48 ,75,,,percent of total billed charges,75% of total billed charges,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.65 ,80,,,percent of total billed charges,80% of total billed charges,$7.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.16 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.32 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.30 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.23 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.65 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.68 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.48 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.68 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.81 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.55 ,$22.14 ,
VALUABLES ENVELOPES,12329,CDM,270,RC,,HCPCS,outpatient,,,$102.38 ,$35.83 ,,$54.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$54.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$76.79 ,75,,,percent of total billed charges,75% of total billed charges,$76.79 ,75,,,percent of total billed charges,75% of total billed charges,$76.79 ,75,,,percent of total billed charges,75% of total billed charges,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$81.90 ,80,,,percent of total billed charges,80% of total billed charges,$32.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$35.83 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$81.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$78.83 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$32.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.96 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$31.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$92.14 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$20.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$97.26 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$81.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$20.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$76.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$76.79 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$20.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$87.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$20.36 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.96 ,$97.26 ,
VALVE BIOPSY MAJ-1555,93002,CDM,272,RC,,HCPCS,outpatient,,,$22.67 ,$7.93 ,,$12.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.15 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$17.00 ,75,,,percent of total billed charges,75% of total billed charges,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.14 ,80,,,percent of total billed charges,80% of total billed charges,$7.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$7.93 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$15.87 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.46 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.10 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.03 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.54 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.55 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.27 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.42 ,$21.54 ,
VALVE LOPEZ M9000,93000,CDM,272,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
VALVE TRANSPORT PED,12578,CDM,270,RC,,HCPCS,outpatient,,,$18.16 ,$6.36 ,,$9.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.73 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.62 ,75,,,percent of total billed charges,75% of total billed charges,$13.62 ,75,,,percent of total billed charges,75% of total billed charges,$13.62 ,75,,,percent of total billed charges,75% of total billed charges,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.53 ,80,,,percent of total billed charges,80% of total billed charges,$5.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.36 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.71 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.54 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.34 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.53 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.89 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.62 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.65 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.54 ,$17.25 ,
VASELINE GAUZE 1 X 8,CDM,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
VASELINE GAUZE 1/2 X 72,12232,CDM,270,RC,,HCPCS,outpatient,,,$14.63 ,$5.12 ,,$7.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.84 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$10.97 ,75,,,percent of total billed charges,75% of total billed charges,$10.97 ,75,,,percent of total billed charges,75% of total billed charges,$10.97 ,75,,,percent of total billed charges,75% of total billed charges,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.70 ,80,,,percent of total billed charges,80% of total billed charges,$4.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.12 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.59 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.54 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$13.90 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$10.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.97 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.44 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.85 ,$13.90 ,
VASELINE GAUZE 3X9,CDM,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
VENTILATOR CIRCUIT SIMPIFIED 72 LONG,11604,CDM,270,RC,,HCPCS,outpatient,,,$15.23 ,$5.33 ,,$8.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$8.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$11.42 ,75,,,percent of total billed charges,75% of total billed charges,$11.42 ,75,,,percent of total billed charges,75% of total billed charges,$11.42 ,75,,,percent of total billed charges,75% of total billed charges,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$12.18 ,80,,,percent of total billed charges,80% of total billed charges,$4.82 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$5.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$10.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$10.66 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$11.73 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$4.77 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$4.72 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$13.71 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$14.47 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.16 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$11.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$11.42 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$12.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.97 ,$14.47 ,
VERSAPORT RPF 5MM TROCAR,11750,CDM,270,RC,,HCPCS,outpatient,,,$384.63 ,$134.62 ,,$206.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$206.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$288.47 ,75,,,percent of total billed charges,75% of total billed charges,$288.47 ,75,,,percent of total billed charges,75% of total billed charges,$288.47 ,75,,,percent of total billed charges,75% of total billed charges,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$307.70 ,80,,,percent of total billed charges,80% of total billed charges,$121.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$134.62 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$307.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$269.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$269.24 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$296.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.43 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$119.24 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$346.17 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$77.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$365.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$307.70 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$76.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.71 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$288.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$288.47 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$77.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$326.94 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$76.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.00 ,$365.40 ,
VERSAPORT RPF 5MM-10MM TROCAR,11751,CDM,270,RC,,HCPCS,outpatient,,,$529.88 ,$185.46 ,,$284.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$284.02 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$397.41 ,75,,,percent of total billed charges,75% of total billed charges,$397.41 ,75,,,percent of total billed charges,75% of total billed charges,$397.41 ,75,,,percent of total billed charges,75% of total billed charges,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$423.90 ,80,,,percent of total billed charges,80% of total billed charges,$167.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$185.46 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$165.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$423.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$370.92 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$408.01 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$165.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$165.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$165.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$103.33 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$164.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$476.89 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$106.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$503.39 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$423.90 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$105.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$397.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$397.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$397.41 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$106.40 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$450.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.39 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$103.33 ,$503.39 ,
VERSATEL ONE SILICONE CONTACT LAYER DRESSING 4X5,30053,CDM,270,RC,,HCPCS,outpatient,,,$37.26 ,$13.04 ,,$19.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.97 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$27.95 ,75,,,percent of total billed charges,75% of total billed charges,$27.95 ,75,,,percent of total billed charges,75% of total billed charges,$27.95 ,75,,,percent of total billed charges,75% of total billed charges,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.81 ,80,,,percent of total billed charges,80% of total billed charges,$11.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$13.04 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$26.08 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$28.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.55 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$33.53 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.40 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.81 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.65 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$27.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$27.95 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$31.67 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.41 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.27 ,$35.40 ,
VIGOR,90378,CDM,250,RC,,HCPCS,outpatient,,,$980.00 ,$343.00 ,,$525.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$525.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$735.00 ,75,,,percent of total billed charges,75% of total billed charges,$735.00 ,75,,,percent of total billed charges,75% of total billed charges,$735.00 ,75,,,percent of total billed charges,75% of total billed charges,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$784.00 ,80,,,percent of total billed charges,80% of total billed charges,$309.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$343.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$784.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$686.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$686.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$754.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$191.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$303.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$882.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$196.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$931.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$784.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$194.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$911.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$735.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$735.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$735.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$196.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$833.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$191.10 ,$931.00 ,
WOUND CARE KIT 2 3/4,12777,CDM,270,RC,,HCPCS,outpatient,,,$26.46 ,$9.26 ,,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.16 ,$25.14 ,
WOUND CARE KIT 4,12781,CDM,270,RC,,HCPCS,outpatient,,,$26.46 ,$9.26 ,,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$14.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$19.85 ,75,,,percent of total billed charges,75% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges,$8.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$9.26 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$18.52 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$20.37 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.28 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$8.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$23.81 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$25.14 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.17 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.61 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$5.31 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$22.49 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.16 ,$25.14 ,
WOUND VAC CANISTER,12208,CDM,270,RC,,HCPCS,outpatient,,,$22.89 ,$8.01 ,,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$12.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$17.17 ,75,,,percent of total billed charges,75% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges,$7.24 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$8.01 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$16.02 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$17.63 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$7.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.46 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$7.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$20.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$21.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.31 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$17.17 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$4.60 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$19.46 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$4.55 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$4.46 ,$21.75 ,
WOUND VAC DRESSING LARGE,12270,CDM,270,RC,,HCPCS,outpatient,,,$185.91 ,$65.07 ,,$99.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.73 ,80,,,percent of total billed charges,80% of total billed charges,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$143.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$167.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$176.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.25 ,$176.61 ,
WOUND VAC DRESSING MEDIUM,12271,CDM,270,RC,,HCPCS,outpatient,,,$185.91 ,$65.07 ,,$99.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$139.43 ,75,,,percent of total billed charges,75% of total billed charges,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.73 ,80,,,percent of total billed charges,80% of total billed charges,$58.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$65.07 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$130.14 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$143.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.63 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$167.32 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$176.61 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.73 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.90 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.43 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$158.02 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.98 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.25 ,$176.61 ,
WOUND VAC TUBING CAP,12211,CDM,270,RC,,HCPCS,outpatient,,,$10.50 ,$3.68 ,,$5.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.63 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.88 ,75,,,percent of total billed charges,75% of total billed charges,$7.88 ,75,,,percent of total billed charges,75% of total billed charges,$7.88 ,75,,,percent of total billed charges,75% of total billed charges,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.40 ,80,,,percent of total billed charges,80% of total billed charges,$3.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.68 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.35 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$8.09 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.05 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.26 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.45 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.98 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$2.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.88 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.11 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.93 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$2.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$2.05 ,$9.98 ,
WOUND VAC VERSAFOAM,12210,CDM,270,RC,,HCPCS,outpatient,,,$41.48 ,$14.52 ,,$22.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$22.23 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$31.11 ,75,,,percent of total billed charges,75% of total billed charges,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$33.18 ,80,,,percent of total billed charges,80% of total billed charges,$13.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$14.52 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$33.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$29.04 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$31.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$12.99 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.09 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$12.86 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$37.33 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$8.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$39.41 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.18 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.58 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.11 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$8.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$35.26 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.09 ,$39.41 ,
WRIST RESTRAINT POSEY,12657,CDM,270,RC,,HCPCS,outpatient,,,$18.10 ,$6.34 ,,$9.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$9.70 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$13.58 ,75,,,percent of total billed charges,75% of total billed charges,$13.58 ,75,,,percent of total billed charges,75% of total billed charges,$13.58 ,75,,,percent of total billed charges,75% of total billed charges,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$14.48 ,80,,,percent of total billed charges,80% of total billed charges,$5.72 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$6.34 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$14.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$12.67 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$13.94 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$5.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$5.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$16.29 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$3.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$17.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$14.48 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$3.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$16.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$13.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$13.58 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$3.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$15.39 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.60 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.53 ,$17.20 ,
XEROFORM 5X9,28558,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
YAUNKER SUCTION TIP,11167,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
flange floating 2 1/4,28728,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
"ostomy pouch 2 1/4""",28727,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
skin temperature sensor,28894,CDM,270,RC,,HCPCS,outpatient,,,$10.00 ,$3.50 ,,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$5.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$7.50 ,75,,,percent of total billed charges,75% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges,$3.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$3.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$7.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$3.13 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$3.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$9.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$9.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$2.01 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$8.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$1.99 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$1.95 ,$9.50 ,
trach tube shiley size 10,28716,CDM,270,RC,,HCPCS,outpatient,,,$424.96 ,$148.74 ,,$227.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$227.78 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$318.72 ,75,,,percent of total billed charges,75% of total billed charges,$318.72 ,75,,,percent of total billed charges,75% of total billed charges,$318.72 ,75,,,percent of total billed charges,75% of total billed charges,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$339.97 ,80,,,percent of total billed charges,80% of total billed charges,$134.37 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$148.74 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$339.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$297.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$297.47 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$327.22 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.87 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$131.74 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$382.46 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$403.71 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$339.97 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$395.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$318.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$318.72 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$361.22 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.87 ,$403.71 ,
Bier Block,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
General,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Local/MAC,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Local/Moderate Sedation,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Local/Sedation,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Moderate Sedation,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Monitored Anesthesia Care,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Regional Block,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Spinal,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
TIVA,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Topical,,CDM,370,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Major,,CDM,360,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Minor,28743,CDM,361,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"24065 Biopsy, soft tissue of upper arm or elbow area, superficial",24065,CDM,361,RC,24065,HCPCS,outpatient,,,"$1,200.00 ",$420.00 ,,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$643.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$900.00 ,75,,,percent of total billed charges,75% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges,$379.44 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$420.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$840.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$924.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$375.72 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$234.00 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$372.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,080.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,140.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$960.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.00 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$900.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$240.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,020.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$238.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$234.00 ,"$1,140.00 ",
43239 EGD W/BIOPSY,43239,CDM,361,RC,43239,HCPCS,outpatient,,,"$3,510.00 ","$1,228.50 ",,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,228.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,702.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,088.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,159.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,334.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,264.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$684.45 ,"$3,334.50 ",
"43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES TechFee",43450,CDM,361,RC,43450,HCPCS,outpatient,,,"$3,510.00 ","$1,228.50 ",,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,228.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,702.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,088.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,159.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,334.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,264.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$684.45 ,"$3,334.50 ",
44970 Laparoscopic Procedures on the Appendix,,CDM,750,RC,44970,HCPCS,outpatient,,,"$3,510.00 ","$1,228.50 ",,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,228.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,702.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,088.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,159.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,334.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,264.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$684.45 ,"$3,334.50 ",
45378 COLONOSCOPY Charges,45378,CDM,750,RC,45378,HCPCS,outpatient,,,"$3,510.00 ","$1,228.50 ",,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,228.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,702.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,088.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,159.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,334.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,264.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$684.45 ,"$3,334.50 ",
45385 COLONSCOPY W/SNARE,45385,CDM,750,RC,45385,HCPCS,outpatient,,,"$1,595.00 ",$558.25 ,,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$854.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges,$504.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$558.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,116.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,228.15 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$499.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$494.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,435.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,515.25 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,276.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,483.35 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,196.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.28 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,355.75 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$317.25 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.03 ,"$1,515.25 ",
ANESTHESIA UNITS - JDHS,6003,CDM,370,RC,,HCPCS,outpatient,,,$295.00 ,$103.25 ,,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$158.12 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$221.25 ,75,,,percent of total billed charges,75% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges,$93.28 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$103.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$227.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$92.36 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.53 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$91.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$265.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$280.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$236.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$274.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$221.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$59.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$250.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.68 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$57.53 ,$280.25 ,
G0121 COLONSCOPY,G0121,CDM,750,RC,G0121,HCPCS,outpatient,,,"$3,510.00 ","$1,228.50 ",,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,881.36 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges,"$1,109.86 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,228.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,457.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,702.70 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,098.98 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$684.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,088.10 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,159.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,334.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,808.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,264.30 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,632.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,983.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$698.14 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$684.45 ,"$3,334.50 ",
KNEE IMMOBILIZER RT,28670,CDM,270,RC,,HCPCS,outpatient,,,$80.00 ,$28.00 ,,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$42.88 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$60.00 ,75,,,percent of total billed charges,75% of total billed charges,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.00 ,80,,,percent of total billed charges,80% of total billed charges,$25.30 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$28.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$56.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$61.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$25.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$24.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$72.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$16.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$76.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$64.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$16.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$68.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.91 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.60 ,$76.00 ,
JDHS PACU,8001,CDM,710,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Endotracheal Intubation,7046,CDM,410,RC,31500,HCPCS,outpatient,,,$480.00 ,$168.00 ,,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$257.28 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$360.00 ,75,,,percent of total billed charges,75% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges,$151.78 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$168.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$336.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$369.60 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$150.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$93.60 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$148.80 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$432.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$456.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$384.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$446.40 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$360.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$96.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$408.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$95.47 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$93.60 ,$456.00 ,
High Flow Nasal Cannula,30255,CDM,271,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Peak Flow Monitoring,20356,CDM,460,RC,94150,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
Pulmonary Function Test Pre,12039,CDM,460,RC,94010,HCPCS,outpatient,,,$463.00 ,$162.05 ,,$248.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$248.17 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$347.25 ,75,,,percent of total billed charges,75% of total billed charges,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$370.40 ,80,,,percent of total billed charges,80% of total billed charges,$146.40 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$162.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$370.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$324.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$324.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$356.51 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$144.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.29 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$143.53 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$416.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$92.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$439.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$370.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.59 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$347.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$92.97 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$393.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.09 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.29 ,$439.85 ,
Pulmonary Function Test Pre and Post,12044,CDM,460,RC,94060,HCPCS,outpatient,,,"$1,350.00 ",$472.50 ,,$723.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$723.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges,$426.87 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$472.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$945.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$945.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,039.50 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$422.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$263.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$418.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,215.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$271.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,282.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,080.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,255.50 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,012.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$271.08 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,147.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$263.25 ,"$1,282.50 ",
RT Assessment,20351,CDM,410,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
RT Incentive Spirometry,120191,CDM,410,RC,94010,HCPCS,outpatient,,,$246.72 ,$86.35 ,,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$132.24 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$185.04 ,75,,,percent of total billed charges,75% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges,$78.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$86.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$172.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$189.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$77.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.25 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.11 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$76.48 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$222.05 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$234.38 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$197.38 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$229.45 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$185.04 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$49.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$209.71 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.07 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.11 ,$234.38 ,
Six Minute Walk,30167,CDM,460,RC,94618,HCPCS,outpatient,,,$156.00 ,$54.60 ,,$83.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$117.00 ,75,,,percent of total billed charges,75% of total billed charges,$117.00 ,75,,,percent of total billed charges,75% of total billed charges,$117.00 ,75,,,percent of total billed charges,75% of total billed charges,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.80 ,80,,,percent of total billed charges,80% of total billed charges,$49.33 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$109.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$120.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.84 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.42 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$140.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$148.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$31.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$145.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$117.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$117.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$132.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$31.03 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.42 ,$148.20 ,
Ventilator Settings,20324,CDM,410,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
10060 I & D ABSCESS SIMPLE CHARGE,202944,CDM,636,RC,Q4176,HCPCS,both,,,$871.00 ,$304.85 ,,$466.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$466.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$696.80 ,80,,,percent of total billed charges,80% of total billed charges,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$304.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$696.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$609.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$609.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$670.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$169.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$270.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$783.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$174.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$827.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$173.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$174.90 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.24 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$169.85 ,$827.45 ,
10060 INCISION & DRAINAGE ABSCESS,30193D,CDM,270,RC,,HCPCS,outpatient,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
10061 I & D ABSCESS COMPLEX CHARGE,28783,CDM,361,RC,15115,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
"10140 I & D OF HEMATOMA, SEROMMA OR FLUID CHARGE",203411,CDM,636,RC,Q4186,HCPCS,both,,,"$8,380.00 ","$2,933.00 ",,"$4,491.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,491.68 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,704.00 ",80,,,percent of total billed charges,80% of total billed charges,"$2,649.76 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,933.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,704.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,866.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,866.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,452.60 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,666.78 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,623.78 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,634.10 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,597.80 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$7,542.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,682.70 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,961.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,704.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,666.78 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,793.40 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,285.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,682.70 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,123.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,666.78 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,634.10 ","$7,961.00 ",
10140 I&D OF HEMATOMA SEROMA OR FLUID COLLECT,28903,CDM,361,RC,28002,HCPCS,outpatient,,,"$3,506.00 ","$1,227.10 ",,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,227.10 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,699.62 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,086.86 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,155.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,330.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,260.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$683.67 ,"$3,330.70 ",
11000 DEBRIDE/REM OF ECZEMATOUS TISSUE,28808,CDM,510,RC,97606,HCPCS,outpatient,,,"$1,088.48 ",$380.97 ,,$583.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$583.43 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$816.36 ,75,,,percent of total billed charges,75% of total billed charges,$816.36 ,75,,,percent of total billed charges,75% of total billed charges,$816.36 ,75,,,percent of total billed charges,75% of total billed charges,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$870.78 ,80,,,percent of total billed charges,80% of total billed charges,$344.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$380.97 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$870.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$761.94 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$838.13 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.80 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$212.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$337.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$979.63 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$218.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,034.06 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$870.78 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$216.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,012.29 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$218.57 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$925.21 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$216.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$212.25 ,"$1,034.06 ",
11001 DEBRIDE/REM OF ECZ TISSUE OR INFECTED,28810,CDM,510,RC,97608,HCPCS,outpatient,,,"$1,007.00 ",$352.45 ,,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$352.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$775.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$312.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$906.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$956.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$936.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.37 ,$956.65 ,
11042 DEBRIDEMENT PARTIAL THICKNESS CHARGE,28787,CDM,761,RC,15274,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
11042 SUBCUTANEOUS TISSUE FIRST 20 SQ CM CHARGE,28785,CDM,761,RC,15272,HCPCS,outpatient,,,$346.56 ,$121.30 ,,$185.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$185.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$259.92 ,75,,,percent of total billed charges,75% of total billed charges,$259.92 ,75,,,percent of total billed charges,75% of total billed charges,$259.92 ,75,,,percent of total billed charges,75% of total billed charges,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$277.25 ,80,,,percent of total billed charges,80% of total billed charges,$109.58 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$121.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$277.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$242.59 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$266.85 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$108.50 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$108.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$108.51 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$107.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$311.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$69.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$329.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$277.25 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$68.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$322.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$259.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$259.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$259.92 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$294.58 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$67.58 ,$329.23 ,
11043 DEBRIDE MUCS/FASCIA 1ST 20CM,28905,CDM,270,RC,Q4148,HCPCS,outpatient,,,$896.00 ,$313.60 ,,$480.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$480.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$672.00 ,75,,,percent of total billed charges,75% of total billed charges,$672.00 ,75,,,percent of total billed charges,75% of total billed charges,$672.00 ,75,,,percent of total billed charges,75% of total billed charges,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$716.80 ,80,,,percent of total billed charges,80% of total billed charges,$283.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$313.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$716.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$627.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$627.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$689.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$174.72 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$277.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$806.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$179.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$851.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$716.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$178.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$833.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$672.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$672.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$672.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$179.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$761.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$178.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$174.72 ,$851.20 ,
11043 SUBCUTANEOUS AND MUSCLE FIRST 20 SQ CM CHARGE,28766,CDM,361,RC,11720,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
11044 DEBRIDE BONE 1ST 20CM,28803,CDM,510,RC,29581,HCPCS,outpatient,,,$473.43 ,$165.70 ,,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.74 ,80,,,percent of total billed charges,80% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$165.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$426.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$449.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$440.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.32 ,$449.76 ,
11044 SUBCUTANEOUS MUSCLE/BONE FIRST 20 SQ CM CHARGE,28786,CDM,761,RC,15273,HCPCS,outpatient,,,"$7,039.00 ","$2,463.65 ",,"$3,772.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,772.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,463.65 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,927.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,927.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,420.03 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,372.61 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,182.09 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$6,335.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,413.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,687.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,546.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,413.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,372.61 ","$6,687.05 ",
11045 DEBRIDE SUBQ TISS EA ADDNL,288333,CDM,636,RC,Q4121,HCPCS,both,,,$871.00 ,$304.85 ,,$466.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$466.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$653.25 ,75,,,percent of total billed charges,75% of total billed charges,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$696.80 ,80,,,percent of total billed charges,80% of total billed charges,$275.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$43.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$696.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$609.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$609.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$670.67 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$272.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.86 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$270.01 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$783.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$827.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.03 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$653.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.12 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$740.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$41.86 ,$827.45 ,
11046 DEBRIDE MUCS/FASCIA EA  ADDTNL,28801,CDM,510,RC,29515,HCPCS,outpatient,,,$351.00 ,$122.85 ,,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$270.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$333.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.45 ,$333.45 ,
11046 SUBCUTANEOUS AND MUSCLE EA ADDL 20SQ CM CHARGE,28747,CDM,361,RC,10140,HCPCS,outpatient,,,"$3,501.00 ","$1,225.35 ",,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,225.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,695.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,085.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,150.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,325.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,255.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$682.70 ,"$3,325.95 ",
11047 DEBRIDE BONE EA ADDTNL 20CM,28806,CDM,361,RC,97602,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
11056 PARING OF BENIGN LESION - 2 TO 4 LESIONS CHARGE,28771,CDM,361,RC,12002,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
11100 BIOPSY(SKIN SUBC),28907,CDM,636,RC,Q4137,HCPCS,both,,,$427.00 ,$149.45 ,,$228.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$228.87 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$320.25 ,75,,,percent of total billed charges,75% of total billed charges,$320.25 ,75,,,percent of total billed charges,75% of total billed charges,$320.25 ,75,,,percent of total billed charges,75% of total billed charges,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$341.60 ,80,,,percent of total billed charges,80% of total billed charges,$135.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$149.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$341.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$298.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$328.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.69 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$132.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$384.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$405.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$341.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$397.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$320.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$320.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.74 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$362.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$83.27 ,$405.65 ,
"11101 BIOPSY, SKIN EACH ADDITIONAL CHARGE",28756,CDM,361,RC,11055,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
11420 REMOVAL/SKIN/LESION/FACE CHARGE,28745,CDM,361,RC,10061,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
11719 TRIMMING/NONDYSTROPHIC NAILS CHARGE,28781,CDM,361,RC,15110,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
11721 DEBRIDE NAIL 6 OR MORE ANY METHOD CHARGE,30240D,CDM,636,RC,Q4160,HCPCS,both,,,$426.00 ,$149.10 ,,$228.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$228.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$319.50 ,75,,,percent of total billed charges,75% of total billed charges,$319.50 ,75,,,percent of total billed charges,75% of total billed charges,$319.50 ,75,,,percent of total billed charges,75% of total billed charges,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$340.80 ,80,,,percent of total billed charges,80% of total billed charges,$134.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$149.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$340.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$298.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$328.02 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$133.38 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$132.06 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$383.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$85.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$404.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$340.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$84.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.18 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$319.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$319.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$319.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$85.54 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$362.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$83.07 ,$404.70 ,
11740 I & D OF SUBUNGUAL HEMATOMA-ER SERV PROC CHARGE,28782,CDM,361,RC,15111,HCPCS,outpatient,,,$621.00 ,$217.35 ,,$332.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$332.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$465.75 ,75,,,percent of total billed charges,75% of total billed charges,$465.75 ,75,,,percent of total billed charges,75% of total billed charges,$465.75 ,75,,,percent of total billed charges,75% of total billed charges,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$496.80 ,80,,,percent of total billed charges,80% of total billed charges,$196.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$217.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$496.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$434.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$434.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$478.17 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$194.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.10 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$192.51 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$558.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$124.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$589.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$496.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$577.53 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$465.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$465.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$465.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.70 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$527.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$121.10 ,$589.95 ,
12013 WOUND REPAIR 2.6 / 5.0 CM,12013,CDM,450,RC,12013,HCPCS,outpatient,,,$203.00 ,$71.05 ,,$108.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.81 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.25 ,75,,,percent of total billed charges,75% of total billed charges,$152.25 ,75,,,percent of total billed charges,75% of total billed charges,$152.25 ,75,,,percent of total billed charges,75% of total billed charges,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$162.40 ,80,,,percent of total billed charges,80% of total billed charges,$64.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$71.05 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$162.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$142.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$142.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$156.31 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$63.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.59 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$62.93 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$182.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$40.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$192.85 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$162.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$40.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$188.79 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$152.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$152.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$40.76 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$172.55 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.38 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.59 ,$192.85 ,
15271 APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1 CHARGE,30243D,CDM,636,RC,Q4160,HCPCS,both,,,$70.00 ,$24.50 ,,$37.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.52 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$52.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.50 ,75,,,percent of total billed charges,75% of total billed charges,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$56.00 ,80,,,percent of total billed charges,80% of total billed charges,$22.13 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$24.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$56.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$49.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$49.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$53.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$21.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.65 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$21.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$63.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$14.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$66.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$13.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$52.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$52.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$14.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$59.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$13.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$13.65 ,$66.50 ,
15271 APPL SKIN SUBSTIT GRAFT TRUNK ARMS LEGS CHARGE,203486,CDM,636,RC,Q4186,HCPCS,both,,,"$10,790.00 ","$3,776.50 ",,"$5,783.44 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,783.44 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$8,632.00 ",80,,,percent of total billed charges,80% of total billed charges,"$3,411.80 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,776.50 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,632.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,553.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,553.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,308.30 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.13 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,378.35 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,104.05 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,344.90 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$9,711.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,166.63 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$10,250.50 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,632.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,146.13 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$10,034.70 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,092.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,166.63 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,171.50 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,146.13 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,104.05 ","$10,250.50 ",
15272 APPLY SKIN GRAFT UP TO 100CM EA  ADD 25S CHARGE,30244D,CDM,636,RC,Q4160,HCPCS,both,,,"$10,919.00 ","$3,821.65 ",,"$5,852.58 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,852.58 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$8,735.20 ",80,,,percent of total billed charges,80% of total billed charges,"$3,452.59 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,821.65 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$8,735.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,643.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,643.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$8,407.63 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,171.79 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,418.74 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,129.21 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$3,384.89 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$9,827.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$2,192.54 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$10,373.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,735.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,171.79 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$10,154.67 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$8,189.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,192.54 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$9,281.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,171.79 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,129.21 ","$10,373.05 ",
15273 APP SKN SUBGRFT T/A/L AREA/100SQ CM 1ST CHARGE,30247,CDM,636,RC,Q4160,HCPCS,both,,,$395.00 ,$138.25 ,,$211.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$211.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$296.25 ,75,,,percent of total billed charges,75% of total billed charges,$296.25 ,75,,,percent of total billed charges,75% of total billed charges,$296.25 ,75,,,percent of total billed charges,75% of total billed charges,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$316.00 ,80,,,percent of total billed charges,80% of total billed charges,$124.90 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$138.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$316.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$276.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$276.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.15 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.03 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$122.45 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$355.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$79.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$375.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$78.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$367.35 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$296.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$296.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$79.32 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$78.57 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$77.03 ,$375.25 ,
15770 GRAFT DERMA-FAT-FASCIA CHARGE,30233,CDM,361,RC,16030,HCPCS,outpatient,,,$544.00 ,$190.40 ,,$291.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$291.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$408.00 ,75,,,percent of total billed charges,75% of total billed charges,$408.00 ,75,,,percent of total billed charges,75% of total billed charges,$408.00 ,75,,,percent of total billed charges,75% of total billed charges,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$435.20 ,80,,,percent of total billed charges,80% of total billed charges,$172.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$190.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$435.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$380.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$380.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$418.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$170.33 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$106.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$168.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$489.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$109.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$516.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$435.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$108.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$505.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$408.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$408.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$408.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$109.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$462.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.20 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$106.08 ,$516.80 ,
16000 INITIAL TREATMENT 1ST DEGREE BURN,28908,CDM,636,RC,Q4117,HCPCS,both,,,$285.00 ,$99.75 ,,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$152.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$213.75 ,75,,,percent of total billed charges,75% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges,$90.12 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$99.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$199.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$219.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$89.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$55.58 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$88.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$256.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$270.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$228.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$265.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$213.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$57.23 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$242.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.69 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$55.58 ,$270.75 ,
16020 BURN DRESSING/DEBRIDEMENT: SMALL CHARGE,28761,CDM,361,RC,11402,HCPCS,outpatient,,,"$1,487.00 ",$520.45 ,,$797.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$797.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$520.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,040.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,144.99 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$460.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,338.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$298.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,412.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,382.91 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$289.97 ,"$1,412.65 ",
16020 DSG AND/OR DEBR PRTL THICK SM,28791,CDM,761,RC,15278,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
16025 BURN DRESSING/DEBRIDEMENT: MEDIUM CHARGE,28780,CDM,361,RC,15003,HCPCS,outpatient,,,$827.00 ,$289.45 ,,$443.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$443.27 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$620.25 ,75,,,percent of total billed charges,75% of total billed charges,$620.25 ,75,,,percent of total billed charges,75% of total billed charges,$620.25 ,75,,,percent of total billed charges,75% of total billed charges,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$661.60 ,80,,,percent of total billed charges,80% of total billed charges,$261.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$289.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$661.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$578.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$578.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$636.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$258.93 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.27 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$256.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$744.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$166.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$785.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$661.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$164.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$769.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$620.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$620.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$620.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$166.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$702.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$164.49 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$161.27 ,$785.65 ,
16025 DSG AND/OR DEBR PRTL THICK MED,28901,CDM,361,RC,27040,HCPCS,outpatient,,,"$3,501.00 ","$1,225.35 ",,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,225.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,695.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,085.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,150.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,325.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,255.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$682.70 ,"$3,325.95 ",
16030 DSG AND/OR DEBR PRTL THICK LG,28797,CDM,361,RC,28010,HCPCS,outpatient,,,"$3,506.00 ","$1,227.10 ",,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,227.10 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,699.62 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,086.86 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,155.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,330.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,260.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$683.67 ,"$3,330.70 ",
17000 DESTROY BENIGN/PREMAL LESION CHARGE,30216,CDM,510,RC,29581,HCPCS,outpatient,,,$473.43 ,$165.70 ,,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$253.76 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$355.07 ,75,,,percent of total billed charges,75% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$378.74 ,80,,,percent of total billed charges,80% of total billed charges,$149.70 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$165.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$378.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$331.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$331.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$364.54 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$92.32 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$146.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$426.09 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$95.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$449.76 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$378.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$440.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.06 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$402.42 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.17 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$92.32 ,$449.76 ,
17110 DESTROY BENIGN LESION 1-14 CHARGE,30225,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
17250 CAUTERIZATION CHARGE,203476,CDM,360,RC,17250,HCPCS,outpatient,,,$700.00 ,$245.00 ,,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$375.20 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$525.00 ,75,,,percent of total billed charges,75% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges,$221.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$245.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$490.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$539.00 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$219.17 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.50 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$217.00 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$630.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$665.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$560.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.00 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$525.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$140.56 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$595.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.23 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.50 ,$665.00 ,
17250 CHEM CAUTERIZATION GRAN TISSUE,301133,CDM,636,RC,Q4187,HCPCS,both,,,"$4,471.00 ","$1,564.85 ",,"$2,396.46 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,396.46 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,576.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,413.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,564.85 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,576.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,129.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,129.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,442.67 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$889.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,399.87 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$871.85 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,386.01 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,023.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$897.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,247.45 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,576.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$889.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,158.03 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,353.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$897.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,800.35 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$889.28 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$871.85 ,"$4,247.45 ",
29445 APPL OF RIGID TOTAL CONTACT LEG CAST CHARGE,28764,CDM,361,RC,11422,HCPCS,outpatient,,,"$3,501.00 ","$1,225.35 ",,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,225.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,695.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,085.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,150.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,325.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,255.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$682.70 ,"$3,325.95 ",
29580 APPL OF UNNA BOOT,30226,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
29580 APPLICATION UNNA BOOT CHARGE,28778,CDM,361,RC,13132,HCPCS,outpatient,,,"$1,267.00 ",$443.45 ,,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$679.11 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$950.25 ,75,,,percent of total billed charges,75% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges,$400.63 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$443.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$886.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$975.59 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$396.70 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.07 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$392.77 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,140.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,203.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,013.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,178.31 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$950.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$254.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,076.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.01 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$247.07 ,"$1,203.65 ",
29580 Unna Boot-WC Charge,301176,CDM,270,RC,,HCPCS,outpatient,,,$301.00 ,$105.35 ,,$161.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$161.34 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$225.75 ,75,,,percent of total billed charges,75% of total billed charges,$225.75 ,75,,,percent of total billed charges,75% of total billed charges,$225.75 ,75,,,percent of total billed charges,75% of total billed charges,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$240.80 ,80,,,percent of total billed charges,80% of total billed charges,$95.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$105.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$240.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$210.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$210.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$231.77 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$94.24 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$93.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$270.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$60.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$285.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$240.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$59.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$279.93 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$225.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$225.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$225.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$60.44 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$255.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.70 ,$285.95 ,
29581 APPL OF MULTILAYER VENOUS WND COMP,30150,CDM,361,RC,15004,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
29700 Removal of Gauntlet/Boot/Body Cast,301165,CDM,270,RC,,HCPCS,outpatient,,,$268.00 ,$93.80 ,,$143.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$143.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$201.00 ,75,,,percent of total billed charges,75% of total billed charges,$201.00 ,75,,,percent of total billed charges,75% of total billed charges,$201.00 ,75,,,percent of total billed charges,75% of total billed charges,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$214.40 ,80,,,percent of total billed charges,80% of total billed charges,$84.74 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$93.80 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$214.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$187.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$187.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$206.36 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$83.91 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$52.26 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$83.08 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$241.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$53.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$254.60 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$214.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$53.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$249.24 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$201.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$201.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$201.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$53.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$227.80 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$53.31 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$52.26 ,$254.60 ,
69210 REMOVAL OF IMPACTED CERUMEN CHARGE,28779,CDM,361,RC,15002,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
93922  Limited bilateral noninvasive physiologic studies of upper/lower extremity arteries,28788,CDM,761,RC,15275,HCPCS,outpatient,,,"$5,243.34 ","$1,835.17 ",,"$2,810.43 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,810.43 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,194.67 ",80,,,percent of total billed charges,80% of total billed charges,"$1,657.94 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,835.17 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,194.67 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,670.34 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,670.34 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,037.37 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,042.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,641.69 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,022.45 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,625.44 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$4,719.01 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,052.86 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,981.17 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,194.67 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,042.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,876.31 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,932.51 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,052.86 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$4,456.84 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,042.90 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,022.45 ","$4,981.17 ",
97597 DEBRIDE DEVIT TISS 1ST 20CM,28794,CDM,361,RC,16025,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
97597 SELECTIVE DEBRIDEMENT < 20 CM CHARGE,20261,CDM,361,RC,97597,HCPCS,outpatient,,,$697.00 ,$243.95 ,,$373.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$373.59 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$522.75 ,75,,,percent of total billed charges,75% of total billed charges,$522.75 ,75,,,percent of total billed charges,75% of total billed charges,$522.75 ,75,,,percent of total billed charges,75% of total billed charges,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$557.60 ,80,,,percent of total billed charges,80% of total billed charges,$220.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$243.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$557.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$487.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$536.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$218.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$135.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$216.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$627.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$139.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$662.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$138.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$648.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$522.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$522.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$522.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.96 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$592.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.63 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$135.92 ,$662.15 ,
97598 DEBRIDE DEVIT TISS EA ADDTNL,30194D,CDM,270,RC,,HCPCS,outpatient,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
97598 SELECTIVE DEBRIDEMENT > 20 CM CHARGE,28789,CDM,761,RC,15276,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
97602 ACTIVE WND MNGNT NON SEL DEBRID,28790,CDM,761,RC,15277,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
97602 WOUND DRESSING CHG/SESSION CHARGE,30208D,CDM,942,RC,99406,HCPCS,outpatient,,,$93.00 ,$32.55 ,,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$49.85 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$69.75 ,75,,,percent of total billed charges,75% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges,$29.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$32.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$71.61 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$29.12 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.14 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$28.83 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$83.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$88.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$74.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.49 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$69.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$18.67 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$79.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.14 ,$88.35 ,
97605 NPWT <-50SQ CM WOUND VAC DME,301591,CDM,636,RC,,HCPCS,both,,,$996.00 ,$348.60 ,,$533.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$533.86 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$747.00 ,75,,,percent of total billed charges,75% of total billed charges,$747.00 ,75,,,percent of total billed charges,75% of total billed charges,$747.00 ,75,,,percent of total billed charges,75% of total billed charges,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$796.80 ,80,,,percent of total billed charges,80% of total billed charges,$314.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$348.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$796.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$697.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$766.92 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$311.85 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$194.22 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$308.76 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$896.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$200.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$946.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$796.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$198.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$926.28 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$747.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$747.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$747.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$200.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$846.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$198.10 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$194.22 ,$946.20 ,
97606 NPWT >-50SQ CM WOUND VAC DME,30183D,CDM,270,RC,,HCPCS,outpatient,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
99201 NEW PATIENT VISIT 1 CHARGE,28762,CDM,361,RC,11403,HCPCS,outpatient,,,"$1,487.00 ",$520.45 ,,$797.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$797.03 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges,$470.19 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$520.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,040.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,040.90 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,144.99 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$465.58 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$289.97 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$460.97 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,338.30 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$298.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,412.65 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,189.60 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,382.91 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,115.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$298.59 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,263.95 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$289.97 ,"$1,412.65 ",
99201 NP VISIT LEVEL 1,28793,CDM,361,RC,16020,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
99202 NP VISIT LEVEL 2,28802,CDM,510,RC,29580,HCPCS,outpatient,,,$240.93 ,$84.33 ,,$129.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$129.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$180.70 ,75,,,percent of total billed charges,75% of total billed charges,$180.70 ,75,,,percent of total billed charges,75% of total billed charges,$180.70 ,75,,,percent of total billed charges,75% of total billed charges,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$192.74 ,80,,,percent of total billed charges,80% of total billed charges,$76.18 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$84.33 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$168.65 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$185.52 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$75.44 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$74.69 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$216.84 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$48.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$228.88 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.74 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$47.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$224.06 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$48.38 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$204.79 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$47.92 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.98 ,$228.88 ,
"99202 WC-NEW OFFICE/OUTPNT, LEV 2, STRAIGHTFORWARD MDM, 15-29 MIN",28757,CDM,361,RC,11056,HCPCS,outpatient,,,$438.00 ,$153.30 ,,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$234.77 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$328.50 ,75,,,percent of total billed charges,75% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges,$138.50 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$153.30 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$306.60 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$337.26 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$137.14 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$85.41 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$135.78 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$394.20 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$416.10 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$350.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$407.34 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$328.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.95 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$372.30 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$87.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$85.41 ,$416.10 ,
99203 NP VISIT LEVEL 3,28809,CDM,510,RC,97607,HCPCS,outpatient,,,"$1,007.00 ",$352.45 ,,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$352.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$775.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$312.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$906.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$956.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$936.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.37 ,$956.65 ,
99204 NP VISIT LEVEL 4,28900,CDM,361,RC,20245,HCPCS,outpatient,,,"$6,038.00 ","$2,113.30 ",,"$3,236.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,236.37 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,909.22 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,113.30 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,226.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,226.60 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,649.26 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,890.50 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,177.41 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,871.78 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$5,434.20 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,212.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,736.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,830.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,615.34 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$4,528.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,212.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,132.30 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,200.96 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,177.41 ","$5,736.10 ",
"99204 WC-NEW OFFICE/OUTPNT, LEV 4, MODERATE MDM, 45-59 MIN",28763,CDM,361,RC,11404,HCPCS,outpatient,,,"$3,501.00 ","$1,225.35 ",,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,876.54 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,107.02 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,225.35 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,450.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,695.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,096.16 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$682.70 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,085.31 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,150.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,325.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,800.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,255.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,625.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$703.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,975.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$696.35 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$682.70 ,"$3,325.95 ",
99205 NP VISIT LEVEL 5,28805,CDM,361,RC,97598,HCPCS,outpatient,,,$197.76 ,$69.22 ,,$106.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$106.00 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$148.32 ,75,,,percent of total billed charges,75% of total billed charges,$148.32 ,75,,,percent of total billed charges,75% of total billed charges,$148.32 ,75,,,percent of total billed charges,75% of total billed charges,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$158.21 ,80,,,percent of total billed charges,80% of total billed charges,$62.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$69.22 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$158.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$138.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$138.43 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$152.28 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$61.92 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$38.56 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$61.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$177.98 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$39.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$187.87 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.21 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$39.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$183.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$148.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$148.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$148.32 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$39.71 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$168.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.33 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$38.56 ,$187.87 ,
"99205 WC-NEW OFFICE/OUTPNT, LEV 5, HIGH MDM, 60-74 MIN",28765,CDM,361,RC,11719,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
99211 EST PT VISIT LEV 1,288356,CDM,636,RC,Q4186,HCPCS,both,,,$956.16 ,$334.66 ,,$512.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$512.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$717.12 ,75,,,percent of total billed charges,75% of total billed charges,$717.12 ,75,,,percent of total billed charges,75% of total billed charges,$717.12 ,75,,,percent of total billed charges,75% of total billed charges,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$764.93 ,80,,,percent of total billed charges,80% of total billed charges,$302.34 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$334.66 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$764.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$669.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$669.31 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$736.24 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$299.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$186.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$296.41 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$860.54 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$192.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$908.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$764.93 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$190.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$889.23 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$717.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$717.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$717.12 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$192.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$812.74 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.18 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$186.45 ,$908.35 ,
99211 LEVEL 1 WOUND DRESSING CHG/SESSION CHARGE,30213D,CDM,636,RC,,HCPCS,both,,,"$2,401.00 ",$840.35 ,,"$1,286.94 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,286.94 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,920.80 ",80,,,percent of total billed charges,80% of total billed charges,$759.20 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$840.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,920.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,680.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,680.70 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,848.77 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$477.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$751.75 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$468.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$744.31 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,160.90 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$482.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,280.95 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,920.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$477.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,232.93 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,800.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$482.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,040.85 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$477.56 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$468.20 ,"$2,280.95 ",
99212 EST PT VISIT LEV 2,28798,CDM,510,RC,29105,HCPCS,outpatient,,,$351.00 ,$122.85 ,,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$188.14 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$263.25 ,75,,,percent of total billed charges,75% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges,$110.99 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$122.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$245.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$270.27 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$109.90 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$108.81 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$315.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$333.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$280.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$326.43 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$298.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$69.81 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.45 ,$333.45 ,
99212 LEVEL 2 WOUND DRESSING CHG/SESSION CHARGE,30211,CDM,361,RC,97597,HCPCS,outpatient,,,$607.00 ,$212.45 ,,$325.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$325.35 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$455.25 ,75,,,percent of total billed charges,75% of total billed charges,$455.25 ,75,,,percent of total billed charges,75% of total billed charges,$455.25 ,75,,,percent of total billed charges,75% of total billed charges,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$485.60 ,80,,,percent of total billed charges,80% of total billed charges,$191.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$212.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$485.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$424.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$424.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$467.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$190.05 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$188.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$546.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$121.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$576.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$485.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$120.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$455.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$455.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$455.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$121.89 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$515.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.73 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$118.37 ,$576.65 ,
"99212 WC-ESTABLISHED OFFICE/OUTPNT, LEV 2, STRAIGHTFORWARD MDM, 10-19 MIN",28777,CDM,361,RC,12042,HCPCS,outpatient,,,$807.00 ,$282.45 ,,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$432.55 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$605.25 ,75,,,percent of total billed charges,75% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges,$255.17 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$282.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$564.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$621.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$252.67 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$250.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$726.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$766.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$645.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$750.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$605.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$162.05 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$685.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$160.51 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.37 ,$766.65 ,
99213 EST PT VISIT LEV 3,,CDM,510,RC,99213,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
99214 EST PT VISIT LEV 4,28795,CDM,361,RC,17250,HCPCS,outpatient,,,$590.77 ,$206.77 ,,$316.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$316.65 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$443.08 ,75,,,percent of total billed charges,75% of total billed charges,$443.08 ,75,,,percent of total billed charges,75% of total billed charges,$443.08 ,75,,,percent of total billed charges,75% of total billed charges,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$472.62 ,80,,,percent of total billed charges,80% of total billed charges,$186.80 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$206.77 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$472.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$413.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$413.54 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$454.89 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$184.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$183.14 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$531.69 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$118.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$561.23 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$472.62 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$117.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$549.42 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$443.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$443.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$443.08 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$118.63 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$502.15 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$117.50 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$115.20 ,$561.23 ,
99215 EST PT VISIT LEV 5,28902,CDM,361,RC,26476,HCPCS,outpatient,,,"$3,506.00 ","$1,227.10 ",,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,879.22 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges,"$1,108.60 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,227.10 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,454.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,699.62 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,097.73 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$683.67 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,086.86 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,155.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,330.70 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,804.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,260.58 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,629.50 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$704.00 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,980.10 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$697.34 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$683.67 ,"$3,330.70 ",
ABD 8X10 JAME,203122,CDM,361,RC,,HCPCS,outpatient,,,$127.00 ,$44.45 ,,$68.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$68.07 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$95.25 ,75,,,percent of total billed charges,75% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges,$40.16 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$44.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$88.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$97.79 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$39.76 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$24.77 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$39.37 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$114.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$25.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$120.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$118.11 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$95.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$25.50 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$107.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.26 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$24.77 ,$120.65 ,
C5271 LOW COST APP SKN SUB GRFT CHARGE,30171,CDM,761,RC,C5271,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
"C5272 Skin sub app trunk,arms,legs,total wound<100 sq cm/ea add 25 sq. cm-Low Cost-WC Charge",30168,CDM,761,RC,C5272,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
"C5273 Skin sub app trunk,arms,legs,total wound>=100sq cm/1st 100 sq cm-Low Cost-WC Charge",30173,CDM,761,RC,C5273,HCPCS,outpatient,,,"$7,039.00 ","$2,463.65 ",,"$3,772.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,772.90 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges,"$2,225.73 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,463.65 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$4,927.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$4,927.30 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,420.03 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,203.91 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,372.61 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,182.09 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$6,335.10 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,413.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,687.05 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,631.20 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,546.27 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$5,279.25 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,413.43 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$5,983.15 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,400.06 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,372.61 ","$6,687.05 ",
"C5274 Skin sub app trunk,arms,legs,total wound>=100 sq cm/ea add 100 sq. cm-Low Cost-WC Charge",30172,CDM,761,RC,C5274,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
"C5275 Skin sub app hands,feet,digits,head,total wound<100 sq cm/1st 25 sq cm-Low Cost-WC Charge",30170,CDM,761,RC,C5275,HCPCS,outpatient,,,"$4,073.00 ","$1,425.55 ",,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,183.13 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges,"$1,287.88 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$1,425.55 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,851.10 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,136.21 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,275.26 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$794.24 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$1,262.63 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,665.70 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,869.35 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,258.40 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,787.89 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$3,054.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$817.86 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$3,462.05 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$810.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$794.24 ,"$3,869.35 ",
"C5276 Skin sub app hands,feet,digits,head,total wound<100 sq cm/ea add 25 sq cm-Low Cost-WC Charge",30169,CDM,761,RC,C5276,HCPCS,outpatient,,,$361.00 ,$126.35 ,,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$193.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$270.75 ,75,,,percent of total billed charges,75% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges,$114.15 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$126.35 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$252.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$277.97 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$113.03 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$111.91 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$324.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$342.95 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$288.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$335.73 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$270.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$306.85 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$71.80 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$70.40 ,$342.95 ,
"G0277 HBOT, full body chamber, 30 minutes",28819,CDM,413,RC,G0277,HCPCS,outpatient,,,"$1,413.43 ",$494.70 ,,$757.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$757.60 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,130.74 ",80,,,percent of total billed charges,80% of total billed charges,$446.93 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$494.70 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,130.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$989.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$989.40 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,088.34 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$442.54 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$275.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$438.16 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,272.09 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$283.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,342.76 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,130.74 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$281.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,314.49 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,060.07 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$283.82 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,201.42 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$281.13 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$275.62 ,"$1,342.76 ",
MESALT 4X4 JAME,20388,CDM,270,RC,,HCPCS,outpatient,,,$35.80 ,$12.53 ,,$19.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$19.19 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.85 ,75,,,percent of total billed charges,75% of total billed charges,$26.85 ,75,,,percent of total billed charges,75% of total billed charges,$26.85 ,75,,,percent of total billed charges,75% of total billed charges,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$28.64 ,80,,,percent of total billed charges,80% of total billed charges,$11.32 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.53 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$28.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$25.06 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$27.57 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$11.21 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$6.98 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$11.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$32.22 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$34.01 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$26.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.85 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$7.19 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$30.43 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$7.12 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$6.98 ,$34.01 ,
NEG PRESS WOUND TX <50 SQ DISPOSABLE - 97607,97607,CDM,510,RC,97607,HCPCS,outpatient,,,"$1,007.00 ",$352.45 ,,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$352.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$775.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$312.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$906.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$956.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$936.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.37 ,$956.65 ,
NEG PRESS WOUND TX >50 DISPOSABLE  - 97608,97608,CDM,510,RC,97608,HCPCS,outpatient,,,"$1,007.00 ",$352.45 ,,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$539.75 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$755.25 ,75,,,percent of total billed charges,75% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges,$318.41 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$352.45 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$704.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$775.39 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$315.29 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$312.17 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$906.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$956.65 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$805.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$936.51 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.21 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$855.95 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.37 ,$956.65 ,
"Q4101 APLIGRAF, PER SQ CM Wound",288386,CDM,636,RC,Q4101,HCPCS,both,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"Q4102 OASIS WOUND MATRIX, PER SQ CM Wound",28831,CDM,636,RC,Q4102,HCPCS,both,,,$50.00 ,$17.50 ,,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$26.80 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$37.50 ,75,,,percent of total billed charges,75% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges,$15.81 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$17.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$35.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$38.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$15.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.75 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$15.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$45.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$47.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$40.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$10.04 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$42.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$9.95 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$9.75 ,$47.50 ,
"Q4106 DERMAGRAFT, PER SQ CM Wound",28832,CDM,636,RC,Q4106,HCPCS,both,,,$155.00 ,$54.25 ,,$83.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$83.08 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$116.25 ,75,,,percent of total billed charges,75% of total billed charges,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$124.00 ,80,,,percent of total billed charges,80% of total billed charges,$49.01 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$54.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$124.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$108.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$108.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$119.35 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$48.53 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.23 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$48.05 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$139.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$31.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$124.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$144.15 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$116.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$31.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$131.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.83 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.23 ,$147.25 ,
Q4110 - Primatrix per sq cm,30154,CDM,636,RC,,HCPCS,both,,,$353.00 ,$123.55 ,,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$189.21 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$264.75 ,75,,,percent of total billed charges,75% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges,$111.62 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$123.55 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$247.10 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$271.81 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$110.52 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.84 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$109.43 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$317.70 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$335.35 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$282.40 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$328.29 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$264.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$70.88 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$300.05 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$70.21 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$68.84 ,$335.35 ,
Q4121 TheraSkin 26TS,20359,CDM,636,RC,Q4121,HCPCS,both,,,"$3,920.10 ","$1,372.04 ",,"$2,101.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,101.17 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$3,136.08 ",80,,,percent of total billed charges,80% of total billed charges,"$1,239.54 ",31.62,,,percent of total billed charges,31.62% of total billed charges,$43.95 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,136.08 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,744.07 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$2,744.07 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$3,018.48 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,227.38 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.86 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,"$1,215.23 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$3,528.09 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$54.42 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,"$3,724.10 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,136.08 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$42.70 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$3,645.69 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$2,940.08 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$43.12 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,"$3,332.09 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$42.70 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$41.86 ,"$3,724.10 ",
Q4124 - Oasis Ultra Tri-Layer Wound Matrix per sq cm,28834,CDM,636,RC,Q4124,HCPCS,both,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$12.60 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.00 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$15.60 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$12.24 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$12.36 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$12.24 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$12.00 ,$142.50 ,
Q4133 - Grafix Prime per sq cm,28836,CDM,636,RC,Q4133,HCPCS,both,,,$510.00 ,$178.50 ,,$273.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$273.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$382.50 ,75,,,percent of total billed charges,75% of total billed charges,$382.50 ,75,,,percent of total billed charges,75% of total billed charges,$382.50 ,75,,,percent of total billed charges,75% of total billed charges,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$408.00 ,80,,,percent of total billed charges,80% of total billed charges,$161.26 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$178.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$408.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$357.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$357.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$392.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$159.68 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$99.45 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$158.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$459.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$102.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$484.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$408.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$101.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$474.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$382.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$382.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$382.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$102.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$433.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.44 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$99.45 ,$484.50 ,
Q4159 Afinity 1.5X1.5,28906,CDM,636,RC,Q4159,HCPCS,both,,,"$1,010.00 ",$353.50 ,,$541.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$541.36 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$757.50 ,75,,,percent of total billed charges,75% of total billed charges,$757.50 ,75,,,percent of total billed charges,75% of total billed charges,$757.50 ,75,,,percent of total billed charges,75% of total billed charges,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$808.00 ,80,,,percent of total billed charges,80% of total billed charges,$319.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$353.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$808.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$707.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$707.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$777.70 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$316.23 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$196.95 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$313.10 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$909.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$202.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$959.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$808.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$200.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$939.30 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$757.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$757.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$757.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$202.81 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$858.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$200.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$196.95 ,$959.50 ,
Q4186 GRAFT ST TIS EPIFIX PURION 4SQ CM,203133,CDM,636,RC,Q4186,HCPCS,both,,,"$8,185.00 ","$2,864.75 ",,"$4,387.16 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$4,387.16 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$6,548.00 ",80,,,percent of total billed charges,80% of total billed charges,"$2,588.10 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$2,864.75 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,548.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$5,729.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$5,729.50 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,302.45 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,628.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,562.72 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,596.08 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,537.35 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$7,366.50 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,643.55 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,775.75 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,548.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,628.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,612.05 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$6,138.75 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,643.55 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$6,957.25 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,628.00 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,596.08 ","$7,775.75 ",
Q4186 GRAFT ST TIS EPIFIX 14MM AMNIO,30198D,CDM,636,RC,,HCPCS,both,,,"$2,452.30 ",$858.31 ,,"$1,314.43 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,314.43 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,961.84 ",80,,,percent of total billed charges,80% of total billed charges,$775.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$858.31 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$767.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,961.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,716.61 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,716.61 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,888.27 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$767.81 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$767.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$767.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$767.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$767.82 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$478.20 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$760.21 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$2,207.07 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$492.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,329.69 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,961.84 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$487.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,280.64 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,839.23 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$492.42 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$2,084.46 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$487.76 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$478.20 ,"$2,329.69 ",
Q4187 EPICORD PER CM,30235D,CDM,270,RC,,HCPCS,outpatient,,,$814.00 ,$284.90 ,,$436.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$436.30 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$610.50 ,75,,,percent of total billed charges,75% of total billed charges,$610.50 ,75,,,percent of total billed charges,75% of total billed charges,$610.50 ,75,,,percent of total billed charges,75% of total billed charges,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$651.20 ,80,,,percent of total billed charges,80% of total billed charges,$257.39 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$284.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$651.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$569.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$569.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$626.78 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$254.86 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$158.73 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$252.34 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$732.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$163.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$773.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$651.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$161.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$757.02 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$610.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$610.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$610.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$163.45 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$691.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.90 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$158.73 ,$773.30 ,
Q4187 GRAFT ST TIS 3X2CM AMNIOCORD PURION,203211,CDM,636,RC,Q4187,HCPCS,both,,,"$9,360.00 ","$3,276.00 ",,"$5,016.96 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$5,016.96 ",53.6,,,percent of total billed charges,53.6% of total billed charges,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$7,488.00 ",80,,,percent of total billed charges,80% of total billed charges,"$2,959.63 ",31.62,,,percent of total billed charges,31.62% of total billed charges,"$3,276.00 ",35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,488.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$6,552.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$6,552.00 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$7,207.20 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,861.70 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$2,930.62 ",31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,825.20 ",19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,"$2,901.60 ",31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$8,424.00 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,"$1,879.49 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$8,892.00 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,488.00 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,861.70 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$8,704.80 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$7,020.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,879.49 ",20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$7,956.00 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,861.70 ",19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,825.20 ","$8,892.00 ",
Q4187 GRAFT ST TIS 6SQ CM EPICORD PURION,30234D,CDM,361,RC,,HCPCS,outpatient,,,$970.00 ,$339.50 ,,$519.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$519.92 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$727.50 ,75,,,percent of total billed charges,75% of total billed charges,$727.50 ,75,,,percent of total billed charges,75% of total billed charges,$727.50 ,75,,,percent of total billed charges,75% of total billed charges,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$776.00 ,80,,,percent of total billed charges,80% of total billed charges,$306.71 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$339.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$776.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$679.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$679.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$746.90 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$303.71 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$189.15 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$300.70 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$873.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$194.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$921.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$776.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$192.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$902.10 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$727.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$727.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$727.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$194.78 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$824.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.93 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$189.15 ,$921.50 ,
Q4196 PuraPlyAM2X4,28837,CDM,636,RC,Q4196,HCPCS,both,,,$615.00 ,$215.25 ,,$329.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$329.64 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$461.25 ,75,,,percent of total billed charges,75% of total billed charges,$461.25 ,75,,,percent of total billed charges,75% of total billed charges,$461.25 ,75,,,percent of total billed charges,75% of total billed charges,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$492.00 ,80,,,percent of total billed charges,80% of total billed charges,$194.46 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$215.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$492.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$430.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$430.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$473.55 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$192.56 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$119.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$190.65 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$553.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$123.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$584.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$492.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$571.95 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$461.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$461.25 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$123.49 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$522.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.32 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$119.93 ,$584.25 ,
Wound Care Charges PCMH_MO,28767,CDM,361,RC,11721,HCPCS,outpatient,,,$145.00 ,$50.75 ,,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.72 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$108.75 ,75,,,percent of total billed charges,75% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges,$45.85 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.75 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$101.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$111.65 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.40 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.28 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.95 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$130.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$137.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$134.85 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$29.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$123.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.28 ,$137.75 ,
"40801 Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated",40801,CDM,450,RC,40801,HCPCS,outpatient,,,$150.00 ,$52.50 ,,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$80.40 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$112.50 ,75,,,percent of total billed charges,75% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges,$47.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$52.50 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$105.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$115.50 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$46.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.25 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$46.50 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$135.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$142.50 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$120.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.50 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$112.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$30.12 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$127.50 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$29.84 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$29.25 ,$142.50 ,
65205 Removal FB Eye Conjunctival Superficial,65205,CDM,361,RC,65205,HCPCS,outpatient,,,$97.00 ,$33.95 ,,$51.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$51.99 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$72.75 ,75,,,percent of total billed charges,75% of total billed charges,$72.75 ,75,,,percent of total billed charges,75% of total billed charges,$72.75 ,75,,,percent of total billed charges,75% of total billed charges,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$77.60 ,80,,,percent of total billed charges,80% of total billed charges,$30.67 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$33.95 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$77.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$67.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$67.90 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$74.69 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$30.37 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$18.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$30.07 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$87.30 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$19.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$92.15 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$77.60 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$19.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.21 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$72.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$72.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$19.48 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$82.45 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$19.29 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$18.92 ,$92.15 ,
00400-ANES PER MINUTE ProFee,400,CDM,961,RC,400,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00790-ANES PER MINUTE ProFee,790,CDM,964,RC,790,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
01480-ANES PER MINUTE ProFee,1480,CDM,964,RC,1480,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
01610-PROC NERVE MUSC SHLDR AXI ProFee,1610,CDM,964,RC,1610,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
36569 PICC Line Insertion,36569,CDM,964,RC,36569,HCPCS,outpatient,,,"$1,487.85 ",$520.75 ,,$310.01 ,100,,,fee schedule,100% Amerigroup fee schedule,$310.01 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$337.91 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$316.21 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$310.01 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$319.31 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$316.21 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$319.31 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$316.21 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$310.01 ,$337.91 ,
"64445 Injection(s), anesthetic agent(s) and/or steroid; sciatic nerves",30270,CDM,964,RC,64445,HCPCS,outpatient,,,,,,$105.18 ,100,,,fee schedule,100% Amerigroup fee schedule,$105.18 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$114.65 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$105.18 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$107.28 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$108.34 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$107.28 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$105.18 ,$114.65 ,
64488 Introduction/injection of anesthetic agent,30271,CDM,964,RC,64488,HCPCS,outpatient,,,,,,$131.54 ,100,,,fee schedule,100% Amerigroup fee schedule,$131.54 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$143.38 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$131.54 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$134.17 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$135.49 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$134.17 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$131.54 ,$143.38 ,
76942 Ultrasonic guidance for needle placement,30269,CDM,964,RC,76942,HCPCS,outpatient,,,,,,$82.45 ,100,,,fee schedule,100% Amerigroup fee schedule,$82.45 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$89.87 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$82.45 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$84.10 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$84.92 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$84.10 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$82.45 ,$89.87 ,
ANES ARTHRS/ENDSCPY DSTL RADIUS ULNA/WRIST/HAND - 01830,1830,CDM,964,RC,1830,HCPCS,outpatient,,,$62.19 ,$21.77 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
ANES NRV/MUS/TND/FASC LOWER LEG/ANKLE/FOOT NOS - 01470,1470,CDM,964,RC,1470,HCPCS,outpatient,,,$62.19 ,$21.77 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
ANES PICC 36569,36569,CDM,750,RC,36569,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"ANES PRO FEE OPEN PROCED ON BONES OF LOW LEG. A, F",1480,CDM,964,RC,1480,HCPCS,outpatient,,,$62.19 ,$21.77 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX - 00813,813,CDM,964,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS - 00811,811,CDM,964,RC,811,HCPCS,outpatient,,,$82.92 ,$29.02 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
ANESTHESIA UPPER GI ENDOSCOPIC PX NOS - 00731,30266,CDM,964,RC,731,HCPCS,outpatient,,,$103.65 ,$36.28 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
Anesthesia  Anorectal Pro Fee,902,CDM,964,RC,902,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
BIOPSY OF THYROID 0 - 00322,30264,CDM,964,RC,322,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
CAT OR MRI SCAN  - 01922,30265,CDM,964,RC,1922,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
Circumcision Anes Pro Fee,920,CDM,964,RC,920,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
ESOPHAGEAL SURGERY  - 00500,30267,CDM,964,RC,500,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
HEAD/NECK/PTRUNK  ANES PRO FEE,300,CDM,964,RC,300,HCPCS,outpatient,,,$103.65 ,$36.28 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
HERNIA REPAIR< 1 YR - 00834,30268,CDM,964,RC,834,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
HERNIA REPAIRS VENTRAL INCISIONAL HERNIA OR WOUND DEHISCENCE 00752,30273,CDM,964,RC,752,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"I & D SKIN, EXT/PER/ATRUNK  - 00400",400,CDM,964,RC,400,HCPCS,outpatient,,,$62.19 ,$21.77 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
INSERTION OF Central Venous Access Device,36555,CDM,961,RC,36555,HCPCS,outpatient,,,,,,$292.33 ,100,,,fee schedule,100% Amerigroup fee schedule,$292.33 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$318.64 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$292.33 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$298.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$301.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$298.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$292.33 ,$318.64 ,
LUMBAR PUNCTURE  - 00635,3021400635,CDM,964,RC,635,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
REPAIR OF HERNIA LOWER ABDOMEN  - 00830,30262,CDM,964,RC,830,HCPCS,outpatient,,,$82.92 ,$29.02 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
REPAIR VENTRAL AND INCISIONAL HERNIA  - 00832,30263,CDM,964,RC,832,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
SURGERY LOWER ABDOMEN  - 00840,840,CDM,964,RC,840,HCPCS,outpatient,,,$124.38 ,$43.53 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
VASCULAR ACCESS  - 00532,532,CDM,964,RC,532,HCPCS,outpatient,,,$82.92 ,$29.02 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
90792 Psychiatric diagnostic Evaluation - with medical services Charge,90792,CDM,961,RC,90792,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$105.37 ,100,,,fee schedule,100% Amerigroup fee schedule,$105.37 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$114.85 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$107.48 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$105.37 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$108.53 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$107.48 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$108.53 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$107.48 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$105.37 ,$114.85 ,
23650 CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES ProFee,23650,CDM,964,RC,23650,HCPCS,outpatient,,,"$2,480.00 ",$868.00 ,,$224.40 ,100,,,fee schedule,100% Amerigroup fee schedule,$224.40 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$244.60 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$228.89 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$224.40 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$231.13 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$228.89 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$231.13 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$228.89 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$224.40 ,$244.60 ,
23655 CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES ProFee,23655,CDM,964,RC,23655,HCPCS,outpatient,,,"$2,500.00 ",$875.00 ,,$266.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$266.92 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$290.94 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$272.26 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$266.92 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$274.93 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$272.26 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$274.93 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$272.26 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$266.92 ,$290.94 ,
27768 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH MANIPULATION. ProFee,27768,CDM,361,RC,27768,HCPCS,outpatient,,,"$1,516.00 ",$530.60 ,,$812.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$812.58 ,53.6,,,percent of total billed charges,53.6% of total billed charges,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,"$1,212.80 ",80,,,percent of total billed charges,80% of total billed charges,$479.36 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$530.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,212.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,061.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,061.20 ",70,,,percent of total billed charges,70% of total billed charges for outpatient setting,"$1,167.32 ",77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$474.66 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$295.62 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$469.96 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,"$1,364.40 ",90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$304.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,440.20 ",95,,,percent of total billed charges,95% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,212.80 ",80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$301.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,"$1,409.88 ",93,,,percent of total billed charges,93% of total billed charges for outpatient setting,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,"$1,137.00 ",75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$304.41 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,"$1,288.60 ",85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$301.53 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$295.62 ,"$1,440.20 ",
99226 OBSV Subsequent 35 minutes,99226,CDM,361,RC,99226,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11055 PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 TechFee,11055,CDM,450,RC,11055,HCPCS,outpatient,,,$174.00 ,$60.90 ,,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$93.26 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$130.50 ,75,,,percent of total billed charges,75% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges,$55.02 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$60.90 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$121.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$133.98 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$54.48 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.93 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$53.94 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$156.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$165.30 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$139.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$161.82 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$130.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$34.94 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$147.90 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$34.61 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$33.93 ,$165.30 ,
25675 CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ TechFee,25675,CDM,450,RC,25675,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
30901 CONTROL ANT. NASAL HEMORRHAGE- ER SERV P,30901,CDM,450,RC,30901,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"99213 - Office/Outpatient - Established Patient, Low 15 min",992131,CDM,982,RC,,HCPCS,outpatient,,,$450.00 ,$157.50 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
99213 CLINIC LEV 3 EST CHARGE,992131,CDM,981,RC,99213,HCPCS,outpatient,,,$215.00 ,$75.25 ,,$40.70 ,100,,,fee schedule,100% Amerigroup fee schedule,$40.70 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$44.36 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$40.70 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.92 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$41.92 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$41.51 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$40.70 ,$44.36 ,
Office Visit Established 25 mins,99214,CDM,982,RC,99214,HCPCS,outpatient,,,$312.00 ,$109.20 ,,$62.71 ,100,,,fee schedule,100% Amerigroup fee schedule,$62.71 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.35 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.71 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$64.59 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$64.59 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$63.96 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$62.71 ,$68.35 ,
90792 PSYCHIATRIC EVALUATION (W/ MED SERVICES),8119858,CDM,900,RC,90792,HCPCS,outpatient,,,$435.00 ,$152.25 ,,$233.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$233.16 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$326.25 ,75,,,percent of total billed charges,75% of total billed charges,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$348.00 ,80,,,percent of total billed charges,80% of total billed charges,$137.55 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$152.25 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$348.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$304.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$304.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$334.95 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$136.20 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.83 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$134.85 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$391.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$87.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$413.25 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$348.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$404.55 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$87.35 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$369.75 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$86.52 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$84.83 ,$413.25 ,
Office Visit new 60 mins,288241,CDM,982,RC,99205,HCPCS,outpatient,,,$600.00 ,$210.00 ,,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$149.46 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$137.12 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$137.12 ,$149.46 ,
99203 Office Visit New Pt. Level 3,99203,CDM,982,RC,99203,HCPCS,outpatient,,,$550.00 ,$192.50 ,,$76.53 ,100,,,fee schedule,100% Amerigroup fee schedule,$76.53 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$83.42 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$78.06 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$76.53 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$78.83 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$78.06 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$78.83 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$78.06 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$76.53 ,$83.42 ,
99204 Office Visit New Pt. Level 4,99204,CDM,982,RC,99204,HCPCS,outpatient,,,$750.00 ,$262.50 ,,$110.51 ,100,,,fee schedule,100% Amerigroup fee schedule,$110.51 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$120.46 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$112.72 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$110.51 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$113.83 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$112.72 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$113.83 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$112.72 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$110.51 ,$120.46 ,
99205 Office Visit New Pt. Level 5,99205,CDM,982,RC,99205,HCPCS,outpatient,,,$950.00 ,$332.50 ,,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,$137.12 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$149.46 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$137.12 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$141.23 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$139.86 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$137.12 ,$149.46 ,
99215  Office Visit Established 40 mins,992151,CDM,982,RC,99215,HCPCS,outpatient,,,$692.40 ,$242.34 ,,$93.46 ,100,,,fee schedule,100% Amerigroup fee schedule,$93.46 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.87 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$93.46 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$96.26 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$96.26 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$95.33 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$93.46 ,$101.87 ,
"65290 - Repair Wound,extrocular muscle",65290,CDM,450,RC,65290,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
"97598-Devitalized Tissue, Each Additional 20 sq cm",97598,CDM,450,RC,97598,HCPCS,outpatient,,,$120.00 ,$42.00 ,,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$64.32 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$90.00 ,75,,,percent of total billed charges,75% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges,$37.94 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$42.00 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$84.00 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$92.40 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$37.57 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.40 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$37.20 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$108.00 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$114.00 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$96.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.60 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$90.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$24.10 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$102.00 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$23.87 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$23.40 ,$114.00 ,
00400 ANES PER MINUTE ProFee,4001,CDM,961,RC,400,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00520 ANESTHESIA CLOSED CHEST W/BRONCHOSCOPY NOS ProFee,520,CDM,964,RC,520,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00532 ACCESS CENTRAL VENOUS CIR ProFee,532,CDM,964,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00790 ANES PER MINUTE ProFee,790,CDM,964,RC,790,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00830 ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS ProFee,830,CDM,964,RC,830,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
00902 ANESTHESIA ANORECTAL PROCEDURE ProFee,902,CDM,964,RC,902,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
01470 PROC NER MUS TEN LOW LEG ProFee,1470,CDM,964,RC,1470,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
"10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS O ProFee",12854,CDM,983,RC,10060,HCPCS,outpatient,,,$258.00 ,$90.30 ,,$66.72 ,100,,,fee schedule,100% Amerigroup fee schedule,$66.72 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$72.72 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.05 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$66.72 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.72 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.05 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.72 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$68.05 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$66.72 ,$72.72 ,
11772 EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED ProFee,11772,CDM,964,RC,11772,HCPCS,outpatient,,,,,,$418.36 ,100,,,fee schedule,100% Amerigroup fee schedule,$418.36 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$456.01 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$418.36 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$426.73 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$430.91 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$426.73 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$418.36 ,$456.01 ,
36555 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; YOUNGER THAN 5 Y ProFee,36555,CDM,964,RC,36555,HCPCS,outpatient,,,,,,$292.33 ,100,,,fee schedule,100% Amerigroup fee schedule,$292.33 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$318.64 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$292.33 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$298.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$301.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$298.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$292.33 ,$318.64 ,
"46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS; ProFee",46260,CDM,964,RC,46260,HCPCS,outpatient,,,,,,$426.83 ,100,,,fee schedule,100% Amerigroup fee schedule,$426.83 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$465.24 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$426.83 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$435.37 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$439.63 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$435.37 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$426.83 ,$465.24 ,
"47533 PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGR ProFee",47533,CDM,361,RC,47533,HCPCS,outpatient,,,$889.00 ,$311.15 ,,$476.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$476.50 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$666.75 ,75,,,percent of total billed charges,75% of total billed charges,$666.75 ,75,,,percent of total billed charges,75% of total billed charges,$666.75 ,75,,,percent of total billed charges,75% of total billed charges,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$711.20 ,80,,,percent of total billed charges,80% of total billed charges,$281.10 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$311.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$711.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$622.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$622.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$684.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$278.35 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$173.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$275.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$800.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$178.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$844.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$711.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$176.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$826.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$666.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$666.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$666.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$178.51 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$755.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$176.82 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$173.36 ,$844.55 ,
"49406 IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYM ProFee",49406,CDM,361,RC,49406,HCPCS,outpatient,,,$656.00 ,$229.60 ,,$351.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$351.62 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$492.00 ,75,,,percent of total billed charges,75% of total billed charges,$492.00 ,75,,,percent of total billed charges,75% of total billed charges,$492.00 ,75,,,percent of total billed charges,75% of total billed charges,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$524.80 ,80,,,percent of total billed charges,80% of total billed charges,$207.43 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$229.60 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$524.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$459.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$459.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$505.12 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$205.39 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$127.92 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$203.36 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$590.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$131.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$623.20 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$524.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$130.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$610.08 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$492.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$492.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$492.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$131.72 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$557.60 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$130.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$127.92 ,$623.20 ,
99213 Follow up Eval 20 -29 min,99213,CDM,982,RC,,HCPCS,outpatient,,,$450.00 ,$157.50 ,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,
99213 Follow up Eval 20 -29 min,99213P,CDM,510,RC,99213,HCPCS,outpatient,,,$131.00 ,$45.85 ,,$70.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$70.22 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$98.25 ,75,,,percent of total billed charges,75% of total billed charges,$98.25 ,75,,,percent of total billed charges,75% of total billed charges,$98.25 ,75,,,percent of total billed charges,75% of total billed charges,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$104.80 ,80,,,percent of total billed charges,80% of total billed charges,$41.42 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$45.85 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$104.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$91.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$91.70 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.87 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$41.02 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$25.55 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$40.61 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$117.90 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$26.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$124.45 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$104.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$26.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$121.83 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$26.30 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$111.35 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.06 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$25.55 ,$124.45 ,
99221 Initial Hospital Care Straightfoward or Low Complexity Charge,99221,CDM,961,RC,99221,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$60.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$60.29 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$65.72 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$60.29 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$60.29 ,$65.72 ,
99221 Initial Hospital Care Straightfoward or Low Complexity Charge,99221,CDM,961,RC,99221,HCPCS,outpatient,,,$181.00 ,$63.35 ,,$60.29 ,100,,,fee schedule,100% Amerigroup fee schedule,$60.29 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$65.72 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$60.29 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.10 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$61.50 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$60.29 ,$65.72 ,
99222 Initial Hosp Care,99222,CDM,961,RC,99222,HCPCS,outpatient,,,$237.12 ,$82.99 ,,$99.20 ,100,,,fee schedule,100% Amerigroup fee schedule,$99.20 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$108.13 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$99.20 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$102.18 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$102.18 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$99.20 ,$108.13 ,
99222 Initial Hosp Care Moderate Complexity Charge,28935,CDM,961,RC,99222,HCPCS,outpatient,,,$237.12 ,$82.99 ,,$99.20 ,100,,,fee schedule,100% Amerigroup fee schedule,$99.20 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$108.13 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$99.20 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$102.18 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$102.18 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$101.18 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$99.20 ,$108.13 ,
99223 Initial Hosp Care High Complexity Charge,28936,CDM,961,RC,99223,HCPCS,outpatient,,,$348.48 ,$121.97 ,,$132.67 ,100,,,fee schedule,100% Amerigroup fee schedule,$132.67 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$144.61 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$135.32 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$132.67 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$136.65 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$135.32 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$136.65 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$135.32 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$132.67 ,$144.61 ,
99231 Subsequent Hosp Care Straightforward or Low Complexity Charge,28937,CDM,961,RC,99231,HCPCS,outpatient,,,$73.00 ,$25.55 ,,$30.80 ,100,,,fee schedule,100% Amerigroup fee schedule,$30.80 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$33.57 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$31.42 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$30.80 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$31.72 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$31.42 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$31.72 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$31.42 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$30.80 ,$33.57 ,
99232 Subsequent Hosp Care Moderate Complexity Charge,99232,CDM,961,RC,99232,HCPCS,outpatient,,,$125.76 ,$44.02 ,,$48.02 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.02 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$52.34 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.02 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.46 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.46 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$48.02 ,$52.34 ,
99232 Subsequent Hosp Care Moderate Complexity Charge,99232,CDM,961,RC,99232,HCPCS,outpatient,,,$125.76 ,$44.02 ,,$48.02 ,100,,,fee schedule,100% Amerigroup fee schedule,$48.02 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$52.34 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.02 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.46 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$49.46 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$48.98 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$48.02 ,$52.34 ,
99233 Subsequent Hosp Care High Complexity Charge,28939,CDM,961,RC,99233,HCPCS,outpatient,,,$249.00 ,$87.15 ,,$67.47 ,100,,,fee schedule,100% Amerigroup fee schedule,$67.47 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$73.54 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$67.47 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$69.49 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$68.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$69.49 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$68.82 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$67.47 ,$73.54 ,
99238 HSP DISCH DAY MGMT 30 MIN ProFee,28943,CDM,961,RC,99238,HCPCS,outpatient,,,$125.76 ,$44.02 ,,$57.11 ,100,,,fee schedule,100% Amerigroup fee schedule,$57.11 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.25 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$57.11 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.82 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.82 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$57.11 ,$62.25 ,
99238 Hosp Discharge Day Manag 30 Mins or Less Charge,28943,CDM,961,RC,99238,HCPCS,outpatient,,,$125.76 ,$44.02 ,,$57.11 ,100,,,fee schedule,100% Amerigroup fee schedule,$57.11 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$62.25 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$57.11 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.82 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$58.82 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$58.25 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$57.11 ,$62.25 ,
99239 Hosp Discharge Day Manag 30 Mins or More Charge,28944,CDM,961,RC,99239,HCPCS,outpatient,,,$188.16 ,$65.86 ,,$79.92 ,100,,,fee schedule,100% Amerigroup fee schedule,$79.92 ,100,,,fee schedule,100% Amerigroup fee schedule,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$87.11 ,109,,,fee schedule,109% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$81.52 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$79.92 ,100,,,fee schedule,100% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$82.32 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$81.52 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,$82.32 ,103,,,fee schedule,103% GA Medicaid fee schedule for physician setting,,,,,other,Not seperately reimbursable per contract terms,$81.52 ,102,,,fee schedule,102% GA Medicaid fee schedule for physician setting,$79.92 ,$87.11 ,
"J0171 Injection, adrenalin, epinephrine",24014,CDM,636,RC,J0171,HCPCS,both,,,$85.00 ,$29.75 ,,$0.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$0.78 ,100,,,fee schedule,100% Amerigroup fee schedule,$63.75 ,75,,,percent of total billed charges,75% of total billed charges,$63.75 ,75,,,percent of total billed charges,75% of total billed charges,$63.75 ,75,,,percent of total billed charges,75% of total billed charges,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$68.00 ,80,,,percent of total billed charges,80% of total billed charges,$26.88 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$0.98 ,125.47,,,fee schedule,125.47% of GA Medicaid fee schedule which is 105% of the regular GA Medicaid fee schedule rate,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$68.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$59.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$59.50 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$65.45 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.95 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$26.61 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.93 ,119.5,,,fee schedule,119.5% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$26.35 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$76.50 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$0.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$80.75 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$68.00 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$0.94 ,119.89,,,fee schedule,119.89% of GA Medicaid fee schedule which is 100% of the regular GA Medicaid fee schedule rate,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$79.05 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$63.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$63.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$0.96 ,123.08,,,fee schedule,123.08% of GA Medicaid fee schedule which is 103% of the regular GA Medicaid fee schedule rate,$72.25 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$0.95 ,121.89,,,fee schedule,121.89% of GA Medicaid fee schedule which is 102% of the regular GA Medicaid fee schedule rate,$0.78 ,$80.75 ,
"13132  Repair, Comp, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or fe",13132,CDM,450,RC,13132,HCPCS,outpatient,,,$289.00 ,$101.15 ,,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$154.90 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$216.75 ,75,,,percent of total billed charges,75% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges,$91.38 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$101.15 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$202.30 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$222.53 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$90.49 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$56.36 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$89.59 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$260.10 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$274.55 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$231.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$268.77 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$216.75 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$58.03 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$245.65 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$57.48 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$56.36 ,$274.55 ,
00378-6232-01 - CITALOPRAM 20 MG TAB [JDHS],,CDM,637,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
72611-0725-25 - KETOROLAC 60 MG/2 ML INJ [JDHS],,CDM,636,RC,,HCPCS,both,,,$185.46 ,$64.91 ,,$99.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$99.41 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$139.10 ,75,,,percent of total billed charges,75% of total billed charges,$139.10 ,75,,,percent of total billed charges,75% of total billed charges,$139.10 ,75,,,percent of total billed charges,75% of total billed charges,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$148.37 ,80,,,percent of total billed charges,80% of total billed charges,$58.64 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$64.91 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$58.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$148.37 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$129.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$129.82 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$142.80 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$58.06 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$58.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$58.07 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.16 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$57.49 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$166.91 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$37.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$176.19 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$148.37 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$36.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$172.48 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$139.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$139.10 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$37.24 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.64 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$36.89 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$36.16 ,$176.19 ,
0111 MED-SUR-GY/PVT,111,CDM,111,RC,,HCPCS,inpatient,,,,,,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ","$2,391.02 ",
0112 OB/PVT,112,CDM,112,RC,,HCPCS,inpatient,,,,,,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ","$2,391.02 ",
0113 PEDS/PVT,113,CDM,113,RC,,HCPCS,inpatient,,,,,,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Pays at Amerigroup DRG rate. See DRG rows. Could also  SHORT STAY 60.2% of charges,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,"$2,322.71 ",102,,,per diem,102% CMS Medicare per diem for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,391.02 ",105,,,per diem,105% CMS Medicare per diem for inpatient stay,,,,,other,Pays at 104% Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,"$2,299.94 ",101,,,per diem,101% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,"$1,594.01 ",70,,,per diem,70% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$2,277.17 ",100,,,per diem,100% CMS Medicare per diem rate for inpatient stay,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 100% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 103% GA Medicaid DRG rate. See DRG rows.,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Pays at 102% GA Medicaid DRG rate. See DRG rows.,"$1,594.01 ","$2,391.02 ",
0270 MED-SUR SUPPLIES,270,CDM,270,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
0271 NON-STER SUPPLY,271,CDM,271,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
0300 LABORATORY,300,CDM,300,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
0301 LAB/CHEMISTRY,301,CDM,301,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
0637 DRUGS/SELF ADMIN,637,CDM,637,RC,,HCPCS,outpatient,,,,,,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,,,other,Not seperately reimbursable per contract terms due to charge amount,,,
11426 EXC B9 LESION MRGN XCP SK TG S/N/H/F/G > 4.0CM ProFee,11426,CDM,450,RC,11426,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
"11305 Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.5 cm > TechFee",11305,CDM,450,RC,11305,HCPCS,outpatient,,,$144.00 ,$50.40 ,,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$77.18 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$108.00 ,75,,,percent of total billed charges,75% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges,$45.53 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$50.40 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$100.80 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$110.88 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$45.09 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.08 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$44.64 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$129.60 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$136.80 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$115.20 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$133.92 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$108.00 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$28.92 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$122.40 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$28.64 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$28.08 ,$136.80 ,
16000 INITIAL TX 1ST DEGREE BURN LOCAL TX TechFee,16000,CDM,450,RC,16000,HCPCS,outpatient,,,$166.00 ,$58.10 ,,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$88.98 ,53.6,,,percent of total billed charges,53.6% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$124.50 ,75,,,percent of total billed charges,75% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges which is 102% of the Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges,$52.49 ,31.62,,,percent of total billed charges,31.62% of total billed charges,$58.10 ,35,,,percent of total billed charges,35% of total billed charges for an outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$116.20 ,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,$127.82 ,77,,,percent of total billed charges,77% of total billed charges for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$51.97 ,31.31,,,percent of total billed charges,31.31% of total billed charges for outpatient setting which is 101% of the CMS Medicare outpatient rate,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$32.37 ,19.5,,,percent of total billed charges,19.5% of total billed charges which is 100% of the GA Medicaid rate for outpatient setting,$51.46 ,31,,,percent of total billed charges,31% of total billed charges for outpatient setting which is 100% of the CMS Medicare outpatient rate,$149.40 ,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$157.70 ,95,,,percent of total billed charges,95% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$132.80 ,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$154.38 ,93,,,percent of total billed charges,93% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$124.50 ,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,$33.33 ,20.08,,,percent of total billed charges,20.08% of total billed charges which is 103% of the GA Medicaid rate for outpatient setting,$141.10 ,85,,,percent of total billed charges,85% of total billed charges for outpatient setting,$33.02 ,19.89,,,percent of total billed charges,19.89% of total billed charges which is 102% of the GA Medicaid rate for outpatient setting,$32.37 ,$157.70 ,
Heart Transplant or Implant of Heart assist System W MCC,1,MS-DRG,100,RC,,,inpatient,,,,,,"$77,084.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$77,084.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$136,389.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$133,767.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$131,144.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$135,078.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$131,144.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$135,078.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$133,767.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$77,084.48 ","$136,389.88 ",
Heart Transplant or Implant of Heart assist System W/O MCC,2,MS-DRG,100,RC,,,inpatient,,,,,,"$51,904.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$51,904.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,837.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,071.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,305.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,954.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,305.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,954.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$90,071.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$51,904.35 ","$91,837.27 ",
"Ecmo or Trach W Mv >96 Hrs or Pdx Exc Face, Mouth & Neck W Maj O.R.",3,MS-DRG,100,RC,,,inpatient,,,,,,"$76,535.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$76,535.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$135,419.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$132,814.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$130,210.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$134,116.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$130,210.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$134,116.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$132,814.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$76,535.77 ","$135,419.01 ",
"Trach W Mv >96 Hrs or Pdx Exc Face, Mouth & Neck W/O Maj O.R.",4,MS-DRG,100,RC,,,inpatient,,,,,,"$55,132.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$55,132.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$97,548.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$95,672.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$93,796.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$96,610.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$93,796.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$96,610.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$95,672.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$55,132.32 ","$97,548.70 ",
Liver Transplant W MCC or Intestinal Transplant,5,MS-DRG,100,RC,,,inpatient,,,,,,"$114,766.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$114,766.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$203,063.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$199,158.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$195,253.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$201,110.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$195,253.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$201,110.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$199,158.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$114,766.84 ","$203,063.38 ",
Liver Transplant W/O MCC,6,MS-DRG,100,RC,,,inpatient,,,,,,"$52,291.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$52,291.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$92,523.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,743.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,964.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,633.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,964.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,633.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$90,743.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$52,291.96 ","$92,523.09 ",
Lung Transplant,7,MS-DRG,100,RC,,,inpatient,,,,,,"$37,328.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$37,328.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$66,047.20 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,777.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$63,506.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$65,412.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$63,506.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$65,412.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$64,777.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$37,328.39 ","$66,047.20 ",
Simultaneous Pancreas/Kidney Transplant,8,MS-DRG,100,RC,,,inpatient,,,,,,"$33,141.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$33,141.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,638.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$57,511.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,383.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,074.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,383.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,074.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$57,511.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$33,141.29 ","$58,638.74 ",
Pancreas Transplant,10,MS-DRG,100,RC,,,inpatient,,,,,,"$18,350.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,350.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,467.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,843.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,218.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,155.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,218.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,155.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,843.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,350.03 ","$32,467.73 ",
"Tracheostomy for Face,Mouth & Neck Diagnoses W MCC",11,MS-DRG,100,RC,,,inpatient,,,,,,"$16,241.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,241.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,737.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,185.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,632.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,461.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,632.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,461.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$28,185.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,241.91 ","$28,737.71 ",
"Tracheostomy for Face,Mouth & Neck Diagnoses W CC",12,MS-DRG,100,RC,,,inpatient,,,,,,"$15,734.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,734.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,839.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,304.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,768.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,571.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,768.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,571.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,304.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,734.31 ","$27,839.60 ",
"Tracheostomy for Face,Mouth & Neck Diagnoses W/O CC/MCC",13,MS-DRG,100,RC,,,inpatient,,,,,,"$7,952.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,952.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,071.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,800.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,530.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,936.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,530.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,936.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,800.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,952.94 ","$14,071.58 ",
Allogeneic Bone Marrow Transplant,14,MS-DRG,100,RC,,,inpatient,,,,,,"$92,721.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$92,721.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$164,057.52 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$160,902.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$157,747.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$162,480.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$157,747.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$162,480.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$160,902.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$92,721.61 ","$164,057.52 ",
Autologous Bone Marrow Transplant W CC/MCC,16,MS-DRG,100,RC,,,inpatient,,,,,,"$26,530.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$26,530.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$46,941.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$46,038.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,135.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$46,490.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,135.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$46,490.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$46,038.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$26,530.23 ","$46,941.41 ",
Autologous Bone Marrow Transplant W/O CC/MCC,17,MS-DRG,100,RC,,,inpatient,,,,,,"$12,077.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,077.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,369.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,958.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,547.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,164.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,547.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,164.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,958.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,077.61 ","$21,369.59 ",
Intracranial Vascular Procedures W Pdx Hemorrhage W MCC,20,MS-DRG,100,RC,,,inpatient,,,,,,"$37,061.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$37,061.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$65,574.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,313.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$63,052.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,943.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$63,052.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,943.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$64,313.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$37,061.13 ","$65,574.33 ",
Intracranial Vascular Procedures W Pdx Hemorrhage W CC,21,MS-DRG,100,RC,,,inpatient,,,,,,"$23,181.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$23,181.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,017.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,228.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,439.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,622.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,439.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,622.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$40,228.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$23,181.90 ","$41,017.03 ",
Intracranial Vascular Procedures W Pdx Hemorrhage W/O CC/MCC,22,MS-DRG,100,RC,,,inpatient,,,,,,"$15,912.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,912.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,154.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,612.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,071.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,883.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,071.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,883.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,612.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,912.23 ","$28,154.40 ",
Craniotomy W Major Device Implant or Acute Cns Pdx W MCC or Chemotherapy Imp,23,MS-DRG,100,RC,,,inpatient,,,,,,"$21,924.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$21,924.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,792.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,046.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,300.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,419.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,300.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,419.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$38,046.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$21,924.50 ","$38,792.24 ",
Cranio W Major Dev Impl/Acute Complex Cns Pdx W/O MCC,24,MS-DRG,100,RC,,,inpatient,,,,,,"$12,015.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,015.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,260.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,851.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,442.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,056.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,442.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,056.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,851.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,015.94 ","$21,260.47 ",
Craniotomy & Endovascular Intracranial Procedures Age >17 W MCC,25,MS-DRG,100,RC,,,inpatient,,,,,,"$18,863.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,863.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,377.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,735.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,093.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,056.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,093.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,056.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,735.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,863.98 ","$33,377.09 ",
Craniotomy & Endovascular Intracranial Procedures Age >17 W CC,26,MS-DRG,100,RC,,,inpatient,,,,,,"$12,755.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,755.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,568.62 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,134.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,700.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,351.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,700.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,351.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,134.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,755.28 ","$22,568.62 ",
Craniotomy & Endovascular Intracranial Procedures Age >17 W/O CC/MCC,27,MS-DRG,100,RC,,,inpatient,,,,,,"$9,938.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,938.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,585.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,247.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,908.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,416.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,908.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,416.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,247.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,938.84 ","$17,585.34 ",
Spinal Procedures W MCC,28,MS-DRG,100,RC,,,inpatient,,,,,,"$18,753.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,753.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,181.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,543.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,905.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,862.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,905.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,862.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,543.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,753.34 ","$33,181.33 ",
Spinal Procedures W CC or Spinal Neurostimulators,29,MS-DRG,100,RC,,,inpatient,,,,,,"$11,700.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,700.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,701.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,303.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,905.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,502.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,905.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,502.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,303.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,700.09 ","$20,701.63 ",
Spinal Procedures W/O CC/MCC,30,MS-DRG,100,RC,,,inpatient,,,,,,"$7,821.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,821.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,839.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,573.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,307.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,706.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,307.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,706.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,573.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,821.74 ","$13,839.44 ",
Ventricular Shunt Procedures Age >17 W MCC,31,MS-DRG,100,RC,,,inpatient,,,,,,"$9,425.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,425.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,677.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,356.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,035.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,516.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,035.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,516.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,356.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,425.64 ","$16,677.30 ",
Ventricular Shunt Procedures Age >17 W CC,32,MS-DRG,100,RC,,,inpatient,,,,,,"$6,036.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,036.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,681.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,476.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,270.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,578.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,270.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,578.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,476.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,036.94 ","$10,681.49 ",
Ventricular Shunt Procedures Age >17 W/O CC/MCC,33,MS-DRG,100,RC,,,inpatient,,,,,,"$4,967.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,967.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,788.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,619.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,450.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,704.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,450.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,704.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,619.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,967.18 ","$8,788.70 ",
Carotid Artery Stent Procedure W MCC,34,MS-DRG,100,RC,,,inpatient,,,,,,"$16,382.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,382.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,985.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,428.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,870.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,707.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,870.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,707.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$28,428.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,382.07 ","$28,985.72 ",
Carotid Artery Stent Procedure W CC,35,MS-DRG,100,RC,,,inpatient,,,,,,"$7,563.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,563.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,382.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,125.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,867.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,253.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,867.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,253.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,125.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,563.46 ","$13,382.45 ",
Carotid Artery Stent Procedure W/O CC/MCC,36,MS-DRG,100,RC,,,inpatient,,,,,,"$4,892.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,892.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,657.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,490.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,324.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,573.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,324.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,573.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,490.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,892.79 ","$8,657.09 ",
Extracranial Procedures W MCC,37,MS-DRG,100,RC,,,inpatient,,,,,,"$10,053.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,053.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,788.37 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,446.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,104.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,617.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,104.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,617.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,446.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,053.59 ","$17,788.37 ",
Extracranial Procedures W CC,38,MS-DRG,100,RC,,,inpatient,,,,,,"$6,834.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,834.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,092.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,860.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,627.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,976.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,627.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,976.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,860.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,834.59 ","$12,092.81 ",
Extracranial Procedures W/O CC/MCC,39,MS-DRG,100,RC,,,inpatient,,,,,,"$4,276.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,276.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,567.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,421.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,276.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,494.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,276.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,494.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,421.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,276.80 ","$7,567.19 ",
Periph/Cranial Nerve & Other Nerv Syst Proc W MCC,40,MS-DRG,100,RC,,,inpatient,,,,,,"$11,080.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,080.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,605.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,228.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,851.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,417.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,851.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,417.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,228.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,080.74 ","$19,605.77 ",
Periph/Cranial Nerve & Other Nerv Syst Proc W CC or Periph Neurostim,41,MS-DRG,100,RC,,,inpatient,,,,,,"$10,796.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,796.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,103.14 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,735.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,368.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,919.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,368.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,919.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,735.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,796.66 ","$19,103.14 ",
Periph/Cranial Nerve & Other Nerv Syst Proc W/O CC/MCC,42,MS-DRG,100,RC,,,inpatient,,,,,,"$5,404.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,404.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,561.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,377.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,194.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,469.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,194.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,469.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,377.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,404.13 ","$9,561.82 ",
Spinal Disorders & Injuries W CC/MCC,52,MS-DRG,100,RC,,,inpatient,,,,,,"$29,296.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$29,296.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,835.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,838.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,841.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,337.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,841.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,337.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$50,838.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$29,296.21 ","$51,835.42 ",
Spinal Disorders & Injuries W/O CC/MCC,53,MS-DRG,100,RC,,,inpatient,,,,,,"$3,039.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,039.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,378.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,274.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,171.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,326.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,171.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,326.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,274.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,039.59 ","$5,378.11 ",
Nervous System Neoplasms W MCC,54,MS-DRG,100,RC,,,inpatient,,,,,,"$6,372.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,372.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,274.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,057.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,841.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,166.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,841.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,166.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,057.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,372.22 ","$11,274.72 ",
Nervous System Neoplasms W/O MCC,55,MS-DRG,100,RC,,,inpatient,,,,,,"$5,078.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,078.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,985.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,812.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,640.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,899.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,640.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,899.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,812.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,078.56 ","$8,985.78 ",
Degenerative Nervous System Disorders W MCC,56,MS-DRG,100,RC,,,inpatient,,,,,,"$10,918.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,918.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,319.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,947.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,576.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,133.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,576.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,133.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,947.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,918.89 ","$19,319.40 ",
Degenerative Nervous System Disorders W/O MCC,57,MS-DRG,100,RC,,,inpatient,,,,,,"$5,970.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,970.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,564.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,361.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,158.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,462.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,158.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,462.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,361.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,970.78 ","$10,564.43 ",
Multiple Sclerosis & Cerebellar Ataxia W MCC,58,MS-DRG,100,RC,,,inpatient,,,,,,"$4,897.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,897.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,665.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,499.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,332.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,582.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,332.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,582.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,499.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,897.65 ","$8,665.69 ",
Multiple Sclerosis & Cerebellar Ataxia W CC,59,MS-DRG,100,RC,,,inpatient,,,,,,"$4,886.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,886.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,646.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,480.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,313.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,563.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,313.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,563.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,480.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,886.81 ","$8,646.51 ",
Multiple Sclerosis & Cerebellar Ataxia W/O CC/MCC,60,MS-DRG,100,RC,,,inpatient,,,,,,"$3,175.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,175.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,510.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,402.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,564.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,402.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,564.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,510.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,175.27 ","$5,618.18 ",
"Ischemic Stroke, Precerebral OCClusion or Transient Ischemia W Thrombolytic",61,MS-DRG,100,RC,,,inpatient,,,,,,"$8,653.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,653.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,310.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,015.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,721.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,163.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,721.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,163.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,015.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,653.03 ","$15,310.29 ",
"Ischemic Stroke, Precerebral OCClusion or Transient Ischemia W Thrombolytic",62,MS-DRG,100,RC,,,inpatient,,,,,,"$6,319.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,319.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,181.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,966.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,751.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,073.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,751.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,073.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,966.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,319.52 ","$11,181.47 ",
"Ischemic Stroke, Precerebral OCClusion or Transient Ischemia W Thrombolytic",63,MS-DRG,100,RC,,,inpatient,,,,,,"$5,567.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,567.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,851.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,662.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,472.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,756.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,472.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,756.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,662.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,567.84 ","$9,851.49 ",
Intracranial Hemorrhage or Cerebral Infarction W MCC,64,MS-DRG,100,RC,,,inpatient,,,,,,"$10,039.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,039.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,762.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,420.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,079.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,591.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,079.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,591.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,420.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,039.01 ","$17,762.58 ",
Intracranial Hemorrhage or Cerebral Infarction W CC or Tpa In 24 Hrs,65,MS-DRG,100,RC,,,inpatient,,,,,,"$5,426.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,426.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,600.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,416.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,231.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,508.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,231.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,508.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,416.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,426.18 ","$9,600.84 ",
Intracranial Hemorrhage or Cerebral Infarction W/O CC/MCC,66,MS-DRG,100,RC,,,inpatient,,,,,,"$3,065.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,065.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,424.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,320.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,215.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,372.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,215.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,372.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,320.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,065.75 ","$5,424.41 ",
Nonspecific Cva & Precerebral OCClusion W/O Infarct W MCC,67,MS-DRG,100,RC,,,inpatient,,,,,,"$4,228.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,228.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,481.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,337.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,193.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,409.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,193.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,409.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,337.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,228.21 ","$7,481.21 ",
Nonspecific Cva & Precerebral OCClusion W/O Infarct W/O MCC,68,MS-DRG,100,RC,,,inpatient,,,,,,"$2,959.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,959.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,236.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,135.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,035.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,186.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,035.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,186.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,135.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,959.60 ","$5,236.58 ",
Transient Ischemia W/O Thrombolytic,69,MS-DRG,100,RC,,,inpatient,,,,,,"$2,840.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,840.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,025.61 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,928.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,832.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,977.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,832.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,977.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,928.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,840.36 ","$5,025.61 ",
Nonspecific Cerebrovascular Disorders W MCC,70,MS-DRG,100,RC,,,inpatient,,,,,,"$7,080.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,080.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,527.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,286.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,045.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,406.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,045.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,406.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,286.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,080.16 ","$12,527.32 ",
Nonspecific Cerebrovascular Disorders W CC,71,MS-DRG,100,RC,,,inpatient,,,,,,"$4,508.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,508.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,977.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,823.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,670.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,900.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,670.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,900.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,823.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,508.55 ","$7,977.22 ",
Nonspecific Cerebrovascular Disorders W/O CC/MCC,72,MS-DRG,100,RC,,,inpatient,,,,,,"$2,543.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,543.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,500.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,413.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,327.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,457.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,327.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,457.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,413.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,543.58 ","$4,500.50 ",
Cranial & Peripheral Nerve Disorders W MCC,73,MS-DRG,100,RC,,,inpatient,,,,,,"$5,585.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,585.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,881.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,691.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,501.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,786.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,501.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,786.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,691.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,585.04 ","$9,881.92 ",
Cranial & Peripheral Nerve Disorders W/O MCC,74,MS-DRG,100,RC,,,inpatient,,,,,,"$3,545.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,545.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,273.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,152.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,032.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,213.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,032.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,213.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,152.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,545.69 ","$6,273.58 ",
Viral Meningitis W CC/MCC,75,MS-DRG,100,RC,,,inpatient,,,,,,"$3,462.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,462.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,126.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,008.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,891.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,067.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,891.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,067.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,008.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,462.71 ","$6,126.76 ",
Viral Meningitis W/O CC/MCC,76,MS-DRG,100,RC,,,inpatient,,,,,,"$2,066.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,066.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,655.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,585.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,515.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,620.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,515.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,620.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,585.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,066.26 ","$3,655.95 ",
Hypertensive Encephalopathy W MCC,77,MS-DRG,100,RC,,,inpatient,,,,,,"$4,070.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,070.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,202.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,064.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,925.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,133.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,925.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,133.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,064.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,070.85 ","$7,202.78 ",
Hypertensive Encephalopathy W CC,78,MS-DRG,100,RC,,,inpatient,,,,,,"$3,715.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,715.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,573.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,446.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,320.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,509.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,320.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,509.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,446.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,715.01 ","$6,573.17 ",
Hypertensive Encephalopathy W/O CC/MCC,79,MS-DRG,100,RC,,,inpatient,,,,,,"$2,489.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,489.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,404.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,319.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,235.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,362.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,235.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,362.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,319.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,489.38 ","$4,404.60 ",
Nontraumatic Stupor & Coma W MCC,80,MS-DRG,100,RC,,,inpatient,,,,,,"$2,942.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,942.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,205.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,105.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,005.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,155.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,005.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,155.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,105.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,942.03 ","$5,205.50 ",
Nontraumatic Stupor & Coma W/O MCC,81,MS-DRG,100,RC,,,inpatient,,,,,,"$1,964.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,964.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,476.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,409.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,343.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,343.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,409.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,964.97 ","$3,476.73 ",
"Traumatic Stupor & Coma, Coma >1 Hr W MCC",82,MS-DRG,100,RC,,,inpatient,,,,,,"$6,689.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,689.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,836.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,609.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,381.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,723.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,381.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,723.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,609.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,689.93 ","$11,836.87 ",
"Traumatic Stupor & Coma, Coma >1 Hr W CC",83,MS-DRG,100,RC,,,inpatient,,,,,,"$4,452.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,452.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,878.68 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,727.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,575.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,802.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,575.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,802.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,727.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,452.85 ","$7,878.68 ",
"Traumatic Stupor & Coma, Coma >1 Hr W/O CC/MCC",84,MS-DRG,100,RC,,,inpatient,,,,,,"$3,284.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,284.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,811.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,700.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,588.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,756.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,588.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,756.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,700.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,284.79 ","$5,811.96 ",
"Traumatic Stupor & Coma, Coma <1 Hr Age >17 W MCC",85,MS-DRG,100,RC,,,inpatient,,,,,,"$5,802.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,802.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,266.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,069.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,871.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,168.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,871.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,168.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,069.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,802.58 ","$10,266.82 ",
"Traumatic Stupor & Coma, Coma <1 Hr Age >17 W CC",86,MS-DRG,100,RC,,,inpatient,,,,,,"$3,237.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,237.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,728.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,508.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,673.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,508.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,673.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,618.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,237.69 ","$5,728.63 ",
"Traumatic Stupor & Coma, Coma <1 Hr Age >17 W/O CC/MCC",87,MS-DRG,100,RC,,,inpatient,,,,,,"$2,503.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,503.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,430.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,345.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,259.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,387.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,259.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,387.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,345.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,503.96 ","$4,430.39 ",
Concussion Age >17 W MCC,88,MS-DRG,100,RC,,,inpatient,,,,,,"$5,012.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,012.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,869.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,698.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,528.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,784.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,528.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,784.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,698.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,012.78 ","$8,869.39 ",
Concussion Age >17 W CC,89,MS-DRG,100,RC,,,inpatient,,,,,,"$4,016.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,016.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,106.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,970.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,833.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,038.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,833.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,038.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,970.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,016.65 ","$7,106.88 ",
Concussion Age >17 W/O CC/MCC,90,MS-DRG,100,RC,,,inpatient,,,,,,"$2,393.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,393.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,234.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,153.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,071.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,193.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,071.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,193.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,153.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,393.32 ","$4,234.63 ",
Other Disorders of Nervous System W MCC,91,MS-DRG,100,RC,,,inpatient,,,,,,"$8,615.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,615.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,244.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,951.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,657.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,097.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,657.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,097.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,951.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,615.65 ","$15,244.15 ",
Other Disorders of Nervous System W CC,92,MS-DRG,100,RC,,,inpatient,,,,,,"$4,288.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,288.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,587.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,441.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,295.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,514.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,295.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,514.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,441.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,288.02 ","$7,587.03 ",
Other Disorders of Nervous System W/O CC/MCC,93,MS-DRG,100,RC,,,inpatient,,,,,,"$3,137.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,137.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,550.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,443.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,337.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,497.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,337.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,497.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,443.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,137.14 ","$5,550.72 ",
Bacterial & Tuberculous Infections of Nervous System W MCC,94,MS-DRG,100,RC,,,inpatient,,,,,,"$17,201.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,201.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,435.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,850.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,264.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,142.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,264.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,142.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$29,850.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,201.40 ","$30,435.40 ",
Bacterial & Tuberculous Infections of Nervous System W CC,95,MS-DRG,100,RC,,,inpatient,,,,,,"$13,765.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,765.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,356.26 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,887.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,419.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,122.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,419.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,122.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,887.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,765.61 ","$24,356.26 ",
Bacterial & Tuberculous Infections of Nervous System W/O CC/MCC,96,MS-DRG,100,RC,,,inpatient,,,,,,"$7,322.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,322.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,955.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,706.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,456.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,830.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,456.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,830.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,706.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,322.00 ","$12,955.22 ",
Non-Bacterial Infect of Nervous Sys Exc Viral Meningitis W MCC,97,MS-DRG,100,RC,,,inpatient,,,,,,"$13,083.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,083.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,149.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,704.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,258.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,926.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,258.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,926.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,704.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,083.46 ","$23,149.29 ",
Non-Bacterial Infect of Nervous Sys Exc Viral Meningitis W CC,98,MS-DRG,100,RC,,,inpatient,,,,,,"$7,566.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,566.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,387.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,129.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,872.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,258.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,872.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,258.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,129.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,566.08 ","$13,387.08 ",
Non-Bacterial Infect of Nervous Sys Exc Viral Meningitis W/O CC/MCC,99,MS-DRG,100,RC,,,inpatient,,,,,,"$3,682.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,682.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,515.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,390.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,265.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,452.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,265.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,452.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,390.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,682.49 ","$6,515.64 ",
Seizures Age >17 W MCC,100,MS-DRG,100,RC,,,inpatient,,,,,,"$6,347.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,347.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,231.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,015.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,799.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,123.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,799.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,123.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,015.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,347.55 ","$11,231.07 ",
Seizures Age >17 W/O MCC,101,MS-DRG,100,RC,,,inpatient,,,,,,"$2,862.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,862.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,063.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,966.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,869.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,015.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,869.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,015.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,966.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,862.04 ","$5,063.97 ",
Headaches Age >17 W MCC,102,MS-DRG,100,RC,,,inpatient,,,,,,"$3,421.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,421.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,054.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,937.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,821.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,995.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,821.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,995.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,937.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,421.59 ","$6,054.01 ",
Headaches Age >17 W/O MCC,103,MS-DRG,100,RC,,,inpatient,,,,,,"$2,635.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,635.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,663.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,573.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,483.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,618.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,483.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,618.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,573.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,635.53 ","$4,663.19 ",
"Craniotomy, Ventricular Shunt & Endovasc Intracranial Proc Age 0-17",104,MS-DRG,100,RC,,,inpatient,,,,,,"$10,422.88 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,422.88 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,441.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,087.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,732.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,264.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,732.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,264.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,087.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,422.88 ","$18,441.79 ",
"Traumatic Stupor & Coma, Coma <1 Hr Age 0-17",105,MS-DRG,100,RC,,,inpatient,,,,,,"$2,773.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,773.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,907.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,812.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,718.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,860.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,718.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,860.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,812.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,773.46 ","$4,907.23 ",
Concussion Age 0-17,106,MS-DRG,100,RC,,,inpatient,,,,,,"$1,954.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,954.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,458.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,392.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,325.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,425.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,325.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,425.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,392.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,954.87 ","$3,458.87 ",
Seizures & Headaches Age 0-17,107,MS-DRG,100,RC,,,inpatient,,,,,,"$2,837.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,837.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,020.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,923.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,827.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,972.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,827.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,972.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,923.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,837.37 ","$5,020.32 ",
Extraocular Procedures Except orbit Age 0-17,108,MS-DRG,100,RC,,,inpatient,,,,,,"$4,071.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,071.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,204.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,065.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,927.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,134.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,927.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,134.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,065.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,071.60 ","$7,204.10 ",
Other Disorders of the Eye Age 0-17,109,MS-DRG,100,RC,,,inpatient,,,,,,"$1,879.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,879.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,324.61 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,260.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,196.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,292.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,196.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,292.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,260.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,879.00 ","$3,324.61 ",
"Other Ear, Nose, Mouth & Throat O.R. Procedures Age 0-17",110,MS-DRG,100,RC,,,inpatient,,,,,,"$4,205.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,205.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,440.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,297.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,154.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,369.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,154.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,369.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,297.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,205.41 ","$7,440.87 ",
Sinus & Mastoid Procedures Age 0-17,111,MS-DRG,100,RC,,,inpatient,,,,,,"$8,244.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,244.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,587.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,306.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,026.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,447.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,026.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,447.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,306.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,244.49 ","$14,587.43 ",
Otitis Media & Uri Age 0-17,112,MS-DRG,100,RC,,,inpatient,,,,,,"$1,691.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,691.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,993.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,935.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,878.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,964.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,878.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,964.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,935.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,691.73 ","$2,993.28 ",
orbital Procedures W CC/MCC,113,MS-DRG,100,RC,,,inpatient,,,,,,"$6,773.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,773.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,985.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,754.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,524.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,869.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,524.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,869.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,754.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,773.66 ","$11,985.01 ",
orbital Procedures W/O CC/MCC,114,MS-DRG,100,RC,,,inpatient,,,,,,"$4,359.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,359.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,713.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,565.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,416.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,639.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,416.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,639.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,565.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,359.41 ","$7,713.34 ",
Extraocular Procedures Except orbit Age >17,115,MS-DRG,100,RC,,,inpatient,,,,,,"$4,700.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,700.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,317.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,157.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,997.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,237.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,997.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,237.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,157.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,700.67 ","$8,317.16 ",
Intraocular Procedures W CC/MCC,116,MS-DRG,100,RC,,,inpatient,,,,,,"$4,801.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,801.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,495.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,332.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,168.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,414.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,168.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,414.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,332.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,801.59 ","$8,495.72 ",
Intraocular Procedures W/O CC/MCC,117,MS-DRG,100,RC,,,inpatient,,,,,,"$3,518.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,518.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,225.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,105.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,985.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,165.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,985.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,165.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,105.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,518.40 ","$6,225.30 ",
"Other Ear, Nose, Mouth & Throat Diagnoses Age 0-17",118,MS-DRG,100,RC,,,inpatient,,,,,,"$2,827.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,827.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,002.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,906.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,810.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,954.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,810.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,954.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,906.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,827.28 ","$5,002.46 ",
Dental & oral Diseases Age 0-17,119,MS-DRG,100,RC,,,inpatient,,,,,,"$2,379.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,379.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,209.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,128.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,047.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,169.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,047.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,169.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,128.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,379.12 ","$4,209.50 ",
Respiratory Infections & Inflammations Age 0-17,120,MS-DRG,100,RC,,,inpatient,,,,,,"$9,238.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,238.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,346.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,032.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,717.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,189.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,717.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,189.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,032.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,238.74 ","$16,346.63 ",
Acute Major Eye Infections W CC/MCC,121,MS-DRG,100,RC,,,inpatient,,,,,,"$2,342.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,342.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,144.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,064.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,984.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,104.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,984.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,104.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,064.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,342.11 ","$4,144.03 ",
Acute Major Eye Infections W/O CC/MCC,122,MS-DRG,100,RC,,,inpatient,,,,,,"$1,996.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,996.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,532.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,465.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,397.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,498.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,397.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,498.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,465.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,996.74 ","$3,532.94 ",
Neurological Eye Disorders,123,MS-DRG,100,RC,,,inpatient,,,,,,"$3,099.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,099.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,484.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,379.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,273.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,431.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,273.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,431.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,379.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,099.77 ","$5,484.59 ",
Other Disorders of the Eye Age >17 W MCC,124,MS-DRG,100,RC,,,inpatient,,,,,,"$3,235.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,235.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,725.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,615.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,505.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,670.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,505.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,670.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,615.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,235.82 ","$5,725.32 ",
Other Disorders of the Eye Age >17 W/O MCC,125,MS-DRG,100,RC,,,inpatient,,,,,,"$2,017.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,017.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,569.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,501.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,432.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,535.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,432.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,535.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,501.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,017.67 ","$3,569.98 ",
Major Head & Neck Procedures W CC/MCC or Major Device,129,MS-DRG,100,RC,,,inpatient,,,,,,"$8,364.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,364.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,799.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,515.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,230.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,657.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,230.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,657.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,515.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,364.47 ","$14,799.73 ",
Major Head & Neck Procedures W/O CC/MCC,130,MS-DRG,100,RC,,,inpatient,,,,,,"$5,165.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,165.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,139.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,963.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,787.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,051.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,787.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,051.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,963.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,165.28 ","$9,139.22 ",
Cranial/Facial Procedures W CC/MCC,131,MS-DRG,100,RC,,,inpatient,,,,,,"$7,527.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,527.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,319.62 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,063.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,807.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,191.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,807.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,191.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,063.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,527.95 ","$13,319.62 ",
Cranial/Facial Procedures W/O CC/MCC,132,MS-DRG,100,RC,,,inpatient,,,,,,"$6,171.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,171.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,920.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,710.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,500.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,815.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,500.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,815.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,710.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,171.87 ","$10,920.24 ",
"Other Ear, Nose, Mouth & Throat O.R. Procedures Age >17 W CC/MCC",133,MS-DRG,100,RC,,,inpatient,,,,,,"$5,615.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,615.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,936.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,745.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,553.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,840.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,553.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,840.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,745.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,615.69 ","$9,936.15 ",
"Other Ear, Nose, Mouth & Throat O.R. Procedures Age >17 W/O CC/MCC",134,MS-DRG,100,RC,,,inpatient,,,,,,"$2,550.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,550.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,512.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,425.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,338.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,469.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,338.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,469.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,425.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,550.31 ","$4,512.40 ",
Sinus & Mastoid Procedures Age >17 W CC/MCC,135,MS-DRG,100,RC,,,inpatient,,,,,,"$7,596.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,596.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,441.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,182.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,924.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,312.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,924.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,312.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,182.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,596.73 ","$13,441.31 ",
Sinus & Mastoid Procedures Age >17 W/O CC/MCC,136,MS-DRG,100,RC,,,inpatient,,,,,,"$3,871.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,871.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,849.62 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,717.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,586.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,783.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,586.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,783.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,717.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,871.25 ","$6,849.62 ",
Mouth Procedures W CC/MCC,137,MS-DRG,100,RC,,,inpatient,,,,,,"$3,459.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,459.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,120.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,003.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,885.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,061.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,885.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,061.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,003.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,459.34 ","$6,120.81 ",
Mouth Procedures W/O CC/MCC,138,MS-DRG,100,RC,,,inpatient,,,,,,"$2,557.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,557.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,524.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,437.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,350.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,481.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,350.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,481.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,437.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,557.41 ","$4,524.97 ",
Salivary Gland Procedures,139,MS-DRG,100,RC,,,inpatient,,,,,,"$3,846.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,846.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,805.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,675.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,544.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,740.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,544.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,740.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,675.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,846.58 ","$6,805.97 ",
Simple Pneumonia & Pleurisy Age 0-17,140,MS-DRG,100,RC,,,inpatient,,,,,,"$2,472.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,472.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,374.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,290.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,206.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,332.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,206.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,332.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,290.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,472.56 ","$4,374.84 ",
Bronchitis & asthma Age 0-17,141,MS-DRG,100,RC,,,inpatient,,,,,,"$2,076.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,076.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,673.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,603.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,532.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,638.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,532.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,638.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,603.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,076.35 ","$3,673.81 ",
Cardiac Congenital & Valvular Disorders Age 0-17,142,MS-DRG,100,RC,,,inpatient,,,,,,"$4,967.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,967.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,789.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,620.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,451.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,704.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,451.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,704.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,620.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,967.55 ","$8,789.36 ",
"Stomach, Esophageal & Duodenal Proc Age 0-17",143,MS-DRG,100,RC,,,inpatient,,,,,,"$8,448.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,448.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,949.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,661.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,374.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,805.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,374.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,805.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,661.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,448.95 ","$14,949.19 ",
Hernia Procedures Age 0-17,144,MS-DRG,100,RC,,,inpatient,,,,,,"$2,374.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,374.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,201.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,120.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,039.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,161.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,039.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,161.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,120.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,374.63 ","$4,201.57 ",
"Esophagitis, Gastroent & Misc Digest Disorders Age 0-17",145,MS-DRG,100,RC,,,inpatient,,,,,,"$2,621.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,621.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,638.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,549.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,460.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,594.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,460.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,594.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,549.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,621.70 ","$4,638.72 ",
"Ear, Nose, Mouth & Throat Malignancy W MCC",146,MS-DRG,100,RC,,,inpatient,,,,,,"$5,037.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,037.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,913.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,742.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,570.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,827.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,570.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,827.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,742.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,037.82 ","$8,913.70 ",
"Ear, Nose, Mouth & Throat Malignancy W CC",147,MS-DRG,100,RC,,,inpatient,,,,,,"$3,763.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,763.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,659.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,531.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,403.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,595.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,403.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,595.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,531.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,763.97 ","$6,659.81 ",
"Ear, Nose, Mouth & Throat Malignancy W/O CC/MCC",148,MS-DRG,100,RC,,,inpatient,,,,,,"$2,848.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,848.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,039.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,942.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,845.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,991.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,845.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,991.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,942.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,848.21 ","$5,039.50 ",
Dysequilibrium,149,MS-DRG,100,RC,,,inpatient,,,,,,"$2,511.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,511.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,442.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,357.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,272.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,400.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,272.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,400.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,357.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,511.06 ","$4,442.96 ",
Epistaxis W MCC,150,MS-DRG,100,RC,,,inpatient,,,,,,"$3,115.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,115.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,513.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,407.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,300.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,460.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,300.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,460.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,407.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,115.84 ","$5,513.03 ",
Epistaxis W/O MCC,151,MS-DRG,100,RC,,,inpatient,,,,,,"$1,907.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,907.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,374.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,309.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,245.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,342.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,245.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,342.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,309.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,907.40 ","$3,374.88 ",
Otitis Media & Uri Age >17 W MCC,152,MS-DRG,100,RC,,,inpatient,,,,,,"$2,823.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,823.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,995.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,899.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,803.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,947.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,803.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,947.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,899.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,823.17 ","$4,995.19 ",
Otitis Media & Uri Age >17 W/O MCC,153,MS-DRG,100,RC,,,inpatient,,,,,,"$2,407.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,407.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,259.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,177.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,095.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,218.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,095.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,218.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,177.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,407.15 ","$4,259.10 ",
"Other Ear, Nose, Mouth & Throat Diagnoses Age >17 W MCC",154,MS-DRG,100,RC,,,inpatient,,,,,,"$4,024.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,024.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,120.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,983.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,846.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,051.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,846.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,051.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,983.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,024.13 ","$7,120.11 ",
"Other Ear, Nose, Mouth & Throat Diagnoses Age >17 W CC",155,MS-DRG,100,RC,,,inpatient,,,,,,"$2,545.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,545.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,503.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,417.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,330.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,460.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,330.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,460.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,417.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,545.45 ","$4,503.80 ",
"Other Ear, Nose, Mouth & Throat Diagnoses Age >17 W/O CC/MCC",156,MS-DRG,100,RC,,,inpatient,,,,,,"$2,018.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,018.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,571.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,502.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,433.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,536.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,433.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,536.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,502.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,018.42 ","$3,571.30 ",
Dental & oral Diseases Age >17 W MCC,157,MS-DRG,100,RC,,,inpatient,,,,,,"$3,906.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,906.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,911.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,778.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,645.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,844.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,645.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,844.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,778.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,906.01 ","$6,911.12 ",
Dental & oral Diseases Age >17 W CC,158,MS-DRG,100,RC,,,inpatient,,,,,,"$3,457.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,457.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,117.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,999.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,882.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,058.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,882.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,058.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,999.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,457.47 ","$6,117.50 ",
Dental & oral Diseases Age >17 W/O CC/MCC,159,MS-DRG,100,RC,,,inpatient,,,,,,"$2,699.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,699.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,776.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,685.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,593.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,731.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,593.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,731.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,685.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,699.82 ","$4,776.94 ",
Other Digestive System Diagnoses Age 0-17,160,MS-DRG,100,RC,,,inpatient,,,,,,"$4,192.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,192.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,418.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,275.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,133.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,347.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,133.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,347.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,275.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,192.70 ","$7,418.38 ",
Hip & Femur Procedures Except Major Joint Age 0-17,161,MS-DRG,100,RC,,,inpatient,,,,,,"$6,644.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,644.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,756.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,530.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,304.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,643.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,304.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,643.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,530.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,644.70 ","$11,756.85 ",
"Lower Extrem & Humer Proc Except Hip,Foot,Femur Age 0-17",162,MS-DRG,100,RC,,,inpatient,,,,,,"$5,145.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,145.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,104.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,929.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,754.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,017.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,754.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,017.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,929.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,145.84 ","$9,104.83 ",
Major Chest Procedures W MCC,163,MS-DRG,100,RC,,,inpatient,,,,,,"$21,275.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$21,275.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,643.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,919.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,195.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,281.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,195.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,281.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$36,919.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$21,275.24 ","$37,643.47 ",
Major Chest Procedures W CC,164,MS-DRG,100,RC,,,inpatient,,,,,,"$9,867.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,867.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,459.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,123.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,787.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,291.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,787.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,291.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,123.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,867.44 ","$17,459.02 ",
Major Chest Procedures W/O CC/MCC,165,MS-DRG,100,RC,,,inpatient,,,,,,"$6,730.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,730.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,908.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,679.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,450.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,794.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,450.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,794.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,679.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,730.67 ","$11,908.96 ",
Other Resp System O.R. Procedures W MCC,166,MS-DRG,100,RC,,,inpatient,,,,,,"$15,620.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,620.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,637.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,106.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,574.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,372.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,574.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,372.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,106.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,620.31 ","$27,637.88 ",
Other Resp System O.R. Procedures W CC,167,MS-DRG,100,RC,,,inpatient,,,,,,"$7,210.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,210.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,758.13 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,512.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,267.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,635.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,267.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,635.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,512.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,210.61 ","$12,758.13 ",
Other Resp System O.R. Procedures W/O CC/MCC,168,MS-DRG,100,RC,,,inpatient,,,,,,"$4,988.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,988.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,825.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,656.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,486.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,740.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,486.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,740.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,656.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,988.11 ","$8,825.74 ",
"Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh Age 0-17",169,MS-DRG,100,RC,,,inpatient,,,,,,"$1,654.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,654.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,927.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,871.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,815.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,899.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,815.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,899.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,871.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,654.73 ","$2,927.80 ",
Cellulitis Age 0-17,170,MS-DRG,100,RC,,,inpatient,,,,,,"$1,914.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,914.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,387.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,322.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,257.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,354.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,257.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,354.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,322.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,914.51 ","$3,387.44 ",
"Trauma To the Skin, Subcut Tiss & Breast Age 0-17",171,MS-DRG,100,RC,,,inpatient,,,,,,"$1,806.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,806.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,196.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,134.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,073.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,165.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,073.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,165.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,134.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,806.48 ","$3,196.31 ",
"Misc Disorders of Nutrition,Metabolism,Fluids/Electrolytes 0-17",172,MS-DRG,100,RC,,,inpatient,,,,,,"$2,923.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,923.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,172.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,072.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,973.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,122.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,973.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,122.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,072.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,923.34 ","$5,172.43 ",
Urethral Procedures Age 0-17,173,MS-DRG,100,RC,,,inpatient,,,,,,"$4,396.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,396.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,778.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,628.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,479.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,703.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,479.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,703.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,628.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,396.04 ","$7,778.16 ",
Kidney & Urinary Tract Infections Age 0-17,174,MS-DRG,100,RC,,,inpatient,,,,,,"$2,167.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,167.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,835.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,761.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,687.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,798.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,687.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,798.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,761.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,167.56 ","$3,835.18 ",
Pulmonary Embolism W MCC,175,MS-DRG,100,RC,,,inpatient,,,,,,"$5,920.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,920.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,475.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,274.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,072.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,375.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,072.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,375.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,274.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,920.69 ","$10,475.81 ",
Pulmonary Embolism W/O MCC,176,MS-DRG,100,RC,,,inpatient,,,,,,"$3,618.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,618.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,402.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,279.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,156.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,340.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,156.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,340.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,279.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,618.57 ","$6,402.54 ",
Respiratory Infections & Inflammations Age >17 W MCC,177,MS-DRG,100,RC,,,inpatient,,,,,,"$7,155.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,155.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,660.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,416.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,173.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,538.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,173.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,538.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,416.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,155.29 ","$12,660.25 ",
Respiratory Infections & Inflammations Age >17 W CC,178,MS-DRG,100,RC,,,inpatient,,,,,,"$5,511.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,511.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,750.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,563.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,375.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,657.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,375.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,657.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,563.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,511.03 ","$9,750.97 ",
Respiratory Infections & Inflammations Age >17 W/O CC/MCC,179,MS-DRG,100,RC,,,inpatient,,,,,,"$2,718.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,718.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,810.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,717.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,625.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,763.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,625.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,763.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,717.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,718.51 ","$4,810.01 ",
Respiratory Neoplasms W MCC,180,MS-DRG,100,RC,,,inpatient,,,,,,"$6,662.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,662.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,788.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,561.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,335.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,675.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,335.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,675.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,561.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,662.65 ","$11,788.59 ",
Respiratory Neoplasms W CC,181,MS-DRG,100,RC,,,inpatient,,,,,,"$4,964.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,964.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,783.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,614.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,445.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,698.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,445.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,698.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,614.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,964.19 ","$8,783.41 ",
Respiratory Neoplasms W/O CC/MCC,182,MS-DRG,100,RC,,,inpatient,,,,,,"$2,831.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,831.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,010.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,914.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,817.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,962.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,817.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,962.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,914.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,831.76 ","$5,010.40 ",
Major Chest Trauma W MCC,183,MS-DRG,100,RC,,,inpatient,,,,,,"$4,907.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,907.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,682.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,515.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,348.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,598.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,348.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,598.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,515.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,907.00 ","$8,682.22 ",
Major Chest Trauma W CC,184,MS-DRG,100,RC,,,inpatient,,,,,,"$3,117.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,117.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,516.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,410.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,304.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,463.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,304.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,463.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,410.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,117.71 ","$5,516.33 ",
Major Chest Trauma W/O CC/MCC,185,MS-DRG,100,RC,,,inpatient,,,,,,"$1,927.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,927.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,410.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,345.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,279.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,377.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,279.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,377.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,345.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,927.59 ","$3,410.59 ",
Pleural Effusion W MCC,186,MS-DRG,100,RC,,,inpatient,,,,,,"$6,088.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,088.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,773.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,566.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,359.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,669.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,359.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,669.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,566.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,088.89 ","$10,773.42 ",
Pleural Effusion W CC,187,MS-DRG,100,RC,,,inpatient,,,,,,"$4,338.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,338.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,675.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,528.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,380.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,601.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,380.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,601.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,528.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,338.10 ","$7,675.65 ",
Pleural Effusion W/O CC/MCC,188,MS-DRG,100,RC,,,inpatient,,,,,,"$2,420.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,420.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,282.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,200.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,118.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,241.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,118.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,241.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,200.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,420.61 ","$4,282.91 ",
Pulmonary Edema & Respiratory Failure,189,MS-DRG,100,RC,,,inpatient,,,,,,"$5,243.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,243.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,278.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,099.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,921.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,188.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,921.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,188.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,099.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,243.77 ","$9,278.10 ",
Chronic Obstructive Pulmonary Disease W MCC,190,MS-DRG,100,RC,,,inpatient,,,,,,"$4,186.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,186.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,407.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,265.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,122.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,336.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,122.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,336.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,265.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,186.72 ","$7,407.80 ",
Chronic Obstructive Pulmonary Disease W CC,191,MS-DRG,100,RC,,,inpatient,,,,,,"$3,351.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,351.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,930.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,816.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,702.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,873.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,702.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,873.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,816.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,351.69 ","$5,930.34 ",
Chronic Obstructive Pulmonary Disease W/O CC/MCC,192,MS-DRG,100,RC,,,inpatient,,,,,,"$2,629.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,629.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,651.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,562.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,473.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,607.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,473.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,607.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,562.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,629.18 ","$4,651.95 ",
Simple Pneumonia & Pleurisy Age >17 W MCC,193,MS-DRG,100,RC,,,inpatient,,,,,,"$5,022.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,022.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,887.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,716.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,545.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,801.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,545.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,801.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,716.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,022.87 ","$8,887.24 ",
Simple Pneumonia & Pleurisy Age >17 W CC,194,MS-DRG,100,RC,,,inpatient,,,,,,"$3,476.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,476.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,151.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,032.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,914.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,092.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,914.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,092.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,032.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,476.54 ","$6,151.23 ",
Simple Pneumonia & Pleurisy Age >17 W/O CC/MCC,195,MS-DRG,100,RC,,,inpatient,,,,,,"$2,620.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,620.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,637.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,548.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,459.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,592.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,459.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,592.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,548.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,620.95 ","$4,637.40 ",
Interstitial Lung Disease W MCC,196,MS-DRG,100,RC,,,inpatient,,,,,,"$4,858.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,858.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,596.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,430.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,265.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,513.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,265.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,513.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,430.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,858.41 ","$8,596.25 ",
Interstitial Lung Disease W CC,197,MS-DRG,100,RC,,,inpatient,,,,,,"$3,820.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,820.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,759.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,629.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,499.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,694.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,499.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,694.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,629.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,820.42 ","$6,759.67 ",
Interstitial Lung Disease W/O CC/MCC,198,MS-DRG,100,RC,,,inpatient,,,,,,"$2,535.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,535.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,485.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,399.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,313.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,442.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,313.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,442.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,399.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,535.36 ","$4,485.95 ",
Pneumothorax W MCC,199,MS-DRG,100,RC,,,inpatient,,,,,,"$5,659.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,659.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,014.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,821.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,629.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,917.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,629.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,917.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,821.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,659.79 ","$10,014.19 ",
Pneumothorax W CC,200,MS-DRG,100,RC,,,inpatient,,,,,,"$2,849.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,849.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,041.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,944.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,847.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,993.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,847.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,993.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,944.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,849.33 ","$5,041.48 ",
Pneumothorax W/O CC/MCC,201,MS-DRG,100,RC,,,inpatient,,,,,,"$2,304.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,304.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,077.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,998.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,920.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,038.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,920.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,038.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,998.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,304.36 ","$4,077.23 ",
Bronchitis & asthma Age >17 W CC/MCC,202,MS-DRG,100,RC,,,inpatient,,,,,,"$3,233.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,233.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,720.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,610.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,500.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,665.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,500.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,665.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,610.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,233.21 ","$5,720.69 ",
Bronchitis & asthma Age >17 W/O CC/MCC,203,MS-DRG,100,RC,,,inpatient,,,,,,"$2,317.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,317.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,101.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,022.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,943.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,061.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,943.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,061.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,022.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,317.82 ","$4,101.04 ",
Respiratory Signs & Symptoms,204,MS-DRG,100,RC,,,inpatient,,,,,,"$2,979.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,979.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,271.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,170.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,068.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,220.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,068.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,220.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,170.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,979.41 ","$5,271.63 ",
Other Respiratory System Diagnoses W MCC,205,MS-DRG,100,RC,,,inpatient,,,,,,"$4,377.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,377.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,745.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,596.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,447.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,671.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,447.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,671.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,596.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,377.72 ","$7,745.75 ",
Other Respiratory System Diagnoses W/O MCC,206,MS-DRG,100,RC,,,inpatient,,,,,,"$2,569.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,569.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,545.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,458.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,370.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,501.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,370.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,501.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,458.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,569.00 ","$4,545.47 ",
Respiratory System Diagnosis W Ventilator Support >96 Hours,207,MS-DRG,100,RC,,,inpatient,,,,,,"$26,113.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$26,113.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$46,204.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,316.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$44,427.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,760.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$44,427.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,760.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$45,316.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$26,113.84 ","$46,204.67 ",
Respiratory System Diagnosis W Ventilator Support <=96 Hours,208,MS-DRG,100,RC,,,inpatient,,,,,,"$7,947.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,947.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,062.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,791.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,521.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,927.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,521.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,927.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,791.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,947.71 ","$14,062.32 ",
Kidney & Urinary Tract Signs & Symptoms Age 0-17,209,MS-DRG,100,RC,,,inpatient,,,,,,"$1,552.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,552.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,746.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,693.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,640.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,720.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,640.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,720.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,693.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,552.31 ","$2,746.59 ",
Urethral Stricture Age 0-17,210,MS-DRG,100,RC,,,inpatient,,,,,,"$2,973.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,973.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,260.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,159.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,058.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,209.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,058.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,209.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,159.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,973.05 ","$5,260.39 ",
Other Kidney & Urinary Tract Diagnoses Age 0-17,211,MS-DRG,100,RC,,,inpatient,,,,,,"$3,149.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,149.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,571.89 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,464.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,357.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,518.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,357.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,518.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,464.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,149.10 ","$5,571.89 ",
Testes Procedures Age 0-17,212,MS-DRG,100,RC,,,inpatient,,,,,,"$2,043.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,043.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,616.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,546.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,477.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,581.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,477.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,581.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,546.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,043.83 ","$3,616.27 ",
Splenectomy Age 0-17,213,MS-DRG,100,RC,,,inpatient,,,,,,"$6,347.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,347.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,230.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,014.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,798.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,122.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,798.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,122.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,014.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,347.18 ","$11,230.41 ",
Red Blood Cell Disorders Age 0-17,214,MS-DRG,100,RC,,,inpatient,,,,,,"$3,057.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,057.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,409.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,305.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,201.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,357.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,201.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,357.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,305.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,057.15 ","$5,409.19 ",
Other Heart assist System Implant,215,MS-DRG,100,RC,,,inpatient,,,,,,"$47,967.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$47,967.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$84,871.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$83,239.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$81,607.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$84,055.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$81,607.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$84,055.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$83,239.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$47,967.69 ","$84,871.91 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W MCC,216,MS-DRG,100,RC,,,inpatient,,,,,,"$40,136.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$40,136.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$71,015.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$69,650.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$68,284.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$70,333.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$68,284.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$70,333.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$69,650.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$40,136.60 ","$71,015.93 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W CC,217,MS-DRG,100,RC,,,inpatient,,,,,,"$23,504.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$23,504.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,588.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,788.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,988.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,188.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,988.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,188.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$40,788.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$23,504.84 ","$41,588.43 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W Card Cath W/O CC/MCC,218,MS-DRG,100,RC,,,inpatient,,,,,,"$18,750.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,750.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,176.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,538.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,900.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,857.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,900.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,857.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,538.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,750.35 ","$33,176.04 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W MCC,219,MS-DRG,100,RC,,,inpatient,,,,,,"$25,976.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$25,976.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,961.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,077.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$44,193.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,519.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$44,193.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$45,519.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$45,077.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$25,976.28 ","$45,961.29 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W CC,220,MS-DRG,100,RC,,,inpatient,,,,,,"$20,763.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,763.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,737.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,030.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,324.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,384.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,324.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,384.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$36,030.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,763.16 ","$36,737.42 ",
Cardiac Valve & Oth Maj Cardiothoracic Proc W/O Card Cath W/O CC/MCC,221,MS-DRG,100,RC,,,inpatient,,,,,,"$20,361.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,361.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,027.13 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,334.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,641.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,680.71 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,641.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,680.71 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$35,334.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,361.72 ","$36,027.13 ",
Cardiac Defib Implant W Cardiac Cath W Ami/Hf/Shock W MCC,222,MS-DRG,100,RC,,,inpatient,,,,,,"$24,557.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$24,557.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,450.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,615.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,779.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,033.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,779.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,033.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$42,615.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$24,557.41 ","$43,450.80 ",
Cardiac Defib Implant W Cardiac Cath W Ami/Hf/Shock W/O MCC,223,MS-DRG,100,RC,,,inpatient,,,,,,"$17,303.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,303.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,615.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,026.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,437.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,320.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,437.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,320.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$30,026.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,303.07 ","$30,615.29 ",
Cardiac Defib Implant W Cardiac Cath W/O Ami/Hf/Shock W MCC,224,MS-DRG,100,RC,,,inpatient,,,,,,"$19,997.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$19,997.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,382.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,702.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,022.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,042.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,022.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,042.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$34,702.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$19,997.66 ","$35,382.97 ",
Cardiac Defib Implant W Cardiac Cath W/O Ami/Hf/Shock W/O MCC,225,MS-DRG,100,RC,,,inpatient,,,,,,"$16,337.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,337.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,906.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,350.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,794.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,628.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,794.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,628.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$28,350.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,337.22 ","$28,906.36 ",
Cardiac Defibrillator Implant W/O Cardiac Cath W MCC,226,MS-DRG,100,RC,,,inpatient,,,,,,"$24,563.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$24,563.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,461.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,625.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,789.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,043.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,789.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,043.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$42,625.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$24,563.39 ","$43,461.38 ",
Cardiac Defibrillator Implant W/O Cardiac Cath W/O MCC,227,MS-DRG,100,RC,,,inpatient,,,,,,"$19,461.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$19,461.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,434.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,772.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,110.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,103.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,110.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,103.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$33,772.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$19,461.66 ","$34,434.59 ",
Other Cardiothoracic Procedures W MCC,228,MS-DRG,100,RC,,,inpatient,,,,,,"$21,333.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$21,333.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,745.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,020.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,294.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,383.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,294.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,383.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$37,020.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$21,333.18 ","$37,745.98 ",
Other Cardiothoracic Procedures W/O MCC,229,MS-DRG,100,RC,,,inpatient,,,,,,"$13,649.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,649.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,151.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,686.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,222.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,919.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,222.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,919.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,686.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,649.73 ","$24,151.24 ",
Coronary Bypass W Ptca W MCC,231,MS-DRG,100,RC,,,inpatient,,,,,,"$24,600.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$24,600.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,526.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,689.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,852.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,107.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,852.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,107.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$42,689.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$24,600.02 ","$43,526.19 ",
Coronary Bypass W Ptca W/O MCC,232,MS-DRG,100,RC,,,inpatient,,,,,,"$20,802.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,802.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,806.86 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,099.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,391.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,452.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,391.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,452.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$36,099.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,802.41 ","$36,806.86 ",
Coronary Bypass W Cardiac Cath W MCC,233,MS-DRG,100,RC,,,inpatient,,,,,,"$24,335.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$24,335.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$43,057.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,229.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,401.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,643.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$41,401.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$42,643.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$42,229.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$24,335.01 ","$43,057.30 ",
Coronary Bypass W Cardiac Cath W/O MCC,234,MS-DRG,100,RC,,,inpatient,,,,,,"$16,910.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,910.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,920.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,345.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,770.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,633.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,770.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,633.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$29,345.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,910.60 ","$29,920.87 ",
Coronary Bypass W/O Cardiac Cath W MCC,235,MS-DRG,100,RC,,,inpatient,,,,,,"$20,071.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,071.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,513.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,830.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,148.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,172.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,148.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,172.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$34,830.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,071.67 ","$35,513.92 ",
Coronary Bypass W/O Cardiac Cath W/O MCC,236,MS-DRG,100,RC,,,inpatient,,,,,,"$14,538.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,538.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,723.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,228.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,733.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,475.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,733.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,475.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,228.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,538.21 ","$25,723.27 ",
Amputation for Circ Sys Disorders Exc Upper Limb & Toe W MCC,239,MS-DRG,100,RC,,,inpatient,,,,,,"$20,707.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,707.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,639.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,934.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,230.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,287.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,230.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,287.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$35,934.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,707.84 ","$36,639.54 ",
Amputation for Circ Sys Disorders Exc Upper Limb & Toe W CC,240,MS-DRG,100,RC,,,inpatient,,,,,,"$10,044.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,044.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,772.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,430.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,088.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,601.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,088.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,601.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,430.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,044.62 ","$17,772.50 ",
Amputation for Circ Sys Disorders Exc Upper Limb & Toe W/O CC/MCC,241,MS-DRG,100,RC,,,inpatient,,,,,,"$4,228.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,228.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,481.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,337.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,194.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,409.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,194.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,409.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,337.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,228.58 ","$7,481.87 ",
Permanent Cardiac Pacemaker Implant W MCC,242,MS-DRG,100,RC,,,inpatient,,,,,,"$15,900.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,900.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,133.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,592.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,051.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,862.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,051.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,862.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,592.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,900.27 ","$28,133.24 ",
Permanent Cardiac Pacemaker Implant W CC,243,MS-DRG,100,RC,,,inpatient,,,,,,"$10,206.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,206.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,058.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,710.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,363.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,884.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,363.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,884.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,710.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,206.09 ","$18,058.21 ",
Permanent Cardiac Pacemaker Implant W/O CC/MCC,244,MS-DRG,100,RC,,,inpatient,,,,,,"$7,909.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,909.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,994.20 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,725.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,455.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,859.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,455.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,859.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,725.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,909.21 ","$13,994.20 ",
Aicd Generator Procedures,245,MS-DRG,100,RC,,,inpatient,,,,,,"$18,516.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,516.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,762.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,132.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,501.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,447.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,501.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,447.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,132.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,516.36 ","$32,762.04 ",
Percutaneous Cardiovascular Procedures W Drug-Eluting Stent W MCC or 4+ Arte,246,MS-DRG,100,RC,,,inpatient,,,,,,"$11,404.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,404.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,179.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,791.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,403.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,985.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,403.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,985.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,791.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,404.81 ","$20,179.16 ",
Perc Cardiovasc Proc W Drug-Eluting Stent W/O MCC,247,MS-DRG,100,RC,,,inpatient,,,,,,"$8,312.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,312.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,708.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,425.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,142.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,567.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,142.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,567.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,425.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,312.89 ","$14,708.46 ",
Percutaneous Cardiovascular Procedures W Non-Drug-Eluting Stent W MCC or 4+,248,MS-DRG,100,RC,,,inpatient,,,,,,"$11,105.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,105.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,648.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,270.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,893.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,459.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,893.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,459.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,270.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,105.03 ","$19,648.76 ",
Perc Cardiovasc Proc W Non-Drug-Eluting Stent W/O MCC,249,MS-DRG,100,RC,,,inpatient,,,,,,"$7,675.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,675.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,580.86 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,319.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,058.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,450.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,058.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,450.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,319.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,675.59 ","$13,580.86 ",
Perc Cardiovasc Proc W/O Coronary Artery Stent W MCC,250,MS-DRG,100,RC,,,inpatient,,,,,,"$9,114.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,114.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,126.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,816.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,506.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,971.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,506.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,971.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,816.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,114.28 ","$16,126.40 ",
Perc Cardiovasc Proc W/O Coronary Artery Stent W/O MCC,251,MS-DRG,100,RC,,,inpatient,,,,,,"$5,576.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,576.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,866.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,676.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,487.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,771.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,487.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,771.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,676.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,576.44 ","$9,866.70 ",
Other Vascular Procedures W MCC,252,MS-DRG,100,RC,,,inpatient,,,,,,"$12,707.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,707.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,483.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,050.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,618.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,267.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,618.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,267.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,050.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,707.06 ","$22,483.31 ",
Other Vascular Procedures W CC,253,MS-DRG,100,RC,,,inpatient,,,,,,"$10,753.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,753.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,027.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,661.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,295.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,844.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,295.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,844.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,661.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,753.68 ","$19,027.09 ",
Other Vascular Procedures W/O CC/MCC,254,MS-DRG,100,RC,,,inpatient,,,,,,"$7,070.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,070.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,509.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,268.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,028.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,389.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,028.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,389.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,268.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,070.07 ","$12,509.47 ",
Upper Limb & Toe Amputation for Circ System Disorders W MCC,255,MS-DRG,100,RC,,,inpatient,,,,,,"$5,646.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,646.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,991.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,798.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,606.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,894.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,606.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,894.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,798.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,646.71 ","$9,991.04 ",
Upper Limb & Toe Amputation for Circ System Disorders W CC,256,MS-DRG,100,RC,,,inpatient,,,,,,"$5,517.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,517.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,762.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,575.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,387.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,669.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,387.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,669.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,575.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,517.76 ","$9,762.87 ",
Upper Limb & Toe Amputation for Circ System Disorders W/O CC/MCC,257,MS-DRG,100,RC,,,inpatient,,,,,,"$2,820.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,820.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,989.90 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,893.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,797.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,941.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,797.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,941.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,893.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,820.18 ","$4,989.90 ",
Cardiac Pacemaker Device Replacement W MCC,258,MS-DRG,100,RC,,,inpatient,,,,,,"$7,961.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,961.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,086.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,815.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,544.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,951.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,544.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,951.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,815.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,961.54 ","$14,086.79 ",
Cardiac Pacemaker Device Replacement W/O MCC,259,MS-DRG,100,RC,,,inpatient,,,,,,"$5,570.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,570.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,856.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,667.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,477.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,762.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,477.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,762.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,667.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,570.83 ","$9,856.78 ",
Cardiac Pacemaker Revision Except Device Replacement W MCC,260,MS-DRG,100,RC,,,inpatient,,,,,,"$10,650.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,650.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,845.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,482.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,120.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,664.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,120.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,664.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,482.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,650.89 ","$18,845.21 ",
Cardiac Pacemaker Revision Except Device Replacement W CC,261,MS-DRG,100,RC,,,inpatient,,,,,,"$5,534.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,534.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,793.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,604.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,416.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,699.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,416.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,699.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,604.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,534.95 ","$9,793.29 ",
Cardiac Pacemaker Revision Except Device Replacement W/O CC/MCC,262,MS-DRG,100,RC,,,inpatient,,,,,,"$5,041.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,041.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,919.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,748.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,576.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,833.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,576.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,833.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,748.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,041.18 ","$8,919.65 ",
Vein Ligation & Stripping,263,MS-DRG,100,RC,,,inpatient,,,,,,"$9,833.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,833.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,398.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,063.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,729.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,230.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,729.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,230.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,063.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,833.06 ","$17,398.18 ",
Other Circulatory System O.R. Procedures,264,MS-DRG,100,RC,,,inpatient,,,,,,"$10,242.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,242.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,123.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,774.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,425.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,948.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,425.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,948.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,774.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,242.72 ","$18,123.02 ",
Aicd Lead Procedures,265,MS-DRG,100,RC,,,inpatient,,,,,,"$9,353.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,353.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,549.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,231.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,913.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,390.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,913.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,390.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,231.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,353.50 ","$16,549.66 ",
Acute Leukemia W/O Major O.R. Procedure Age 0-17,266,MS-DRG,100,RC,,,inpatient,,,,,,"$18,017.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,017.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,879.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,266.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,653.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,573.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,653.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,573.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,266.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,017.74 ","$31,879.79 ",
Viral Illness & Fever Age 0-17,267,MS-DRG,100,RC,,,inpatient,,,,,,"$2,057.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,057.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,640.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,570.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,500.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,605.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,500.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,605.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,570.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,057.29 ","$3,640.08 ",
Septicemia or Severe Sepsis Age 0-17,268,MS-DRG,100,RC,,,inpatient,,,,,,"$9,935.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,935.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,578.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,240.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,902.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,409.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,902.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,409.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,240.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,935.10 ","$17,578.73 ",
Traumatic Injury Age 0-17,269,MS-DRG,100,RC,,,inpatient,,,,,,"$1,675.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,675.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,964.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,907.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,850.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,935.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,850.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,935.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,907.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,675.29 ","$2,964.18 ",
Allergic Reactions Age 0-17,270,MS-DRG,100,RC,,,inpatient,,,,,,"$1,068.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,068.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,890.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,854.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,818.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,872.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,818.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,872.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$1,854.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,068.64 ","$1,890.80 ",
Poisoning & Toxic Effects of Drugs Age 0-17,271,MS-DRG,100,RC,,,inpatient,,,,,,"$2,007.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,007.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,552.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,483.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,415.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,517.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,415.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,517.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,483.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,007.58 ","$3,552.12 ",
Percutaneous Intracardiac Procedures W MCC,273,MS-DRG,100,RC,,,inpatient,,,,,,"$14,559.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,559.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,760.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,265.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,770.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,513.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,770.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,513.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,265.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,559.52 ","$25,760.97 ",
Percutaneous Intracardiac Procedures W/O MCC,274,MS-DRG,100,RC,,,inpatient,,,,,,"$7,736.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,736.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,689.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,426.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,162.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,557.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,162.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,557.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,426.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,736.89 ","$13,689.32 ",
Aortic And Heart assist Procedures Except Pulsation Balloon W MCC,275,MS-DRG,100,RC,,,inpatient,,,,,,"$18,711.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,711.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,106.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,469.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,833.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,788.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,833.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,788.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,469.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,711.10 ","$33,106.60 ",
Aortic And Heart assist Procedures Except Pulsation Balloon W/O MCC,276,MS-DRG,100,RC,,,inpatient,,,,,,"$13,372.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,372.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,659.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,204.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,749.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,432.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,749.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,432.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,204.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,372.02 ","$23,659.85 ",
Other Major Cardiovascular Procedures W MCC,277,MS-DRG,100,RC,,,inpatient,,,,,,"$20,184.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,184.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,713.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,026.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,340.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,370.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,340.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,370.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$35,026.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,184.55 ","$35,713.65 ",
Other Major Cardiovascular Procedures W CC,278,MS-DRG,100,RC,,,inpatient,,,,,,"$13,330.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,330.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,585.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,132.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,678.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,359.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,678.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,359.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,132.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,330.15 ","$23,585.78 ",
Other Major Cardiovascular Procedures W/O CC/MCC,279,MS-DRG,100,RC,,,inpatient,,,,,,"$8,399.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,399.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,861.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,575.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,289.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,718.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,289.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,718.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,575.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,399.23 ","$14,861.23 ",
"Acute Myocardial Infarction, Discharged Alive W MCC",280,MS-DRG,100,RC,,,inpatient,,,,,,"$6,219.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,219.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,004.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,792.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,580.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,898.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,580.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,898.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,792.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,219.34 ","$11,004.23 ",
"Acute Myocardial Infarction, Discharged Alive W CC",281,MS-DRG,100,RC,,,inpatient,,,,,,"$3,679.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,679.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,511.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,385.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,260.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,448.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,260.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,448.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,385.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,679.87 ","$6,511.01 ",
"Acute Myocardial Infarction, Discharged Alive W/O CC/MCC",282,MS-DRG,100,RC,,,inpatient,,,,,,"$3,679.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,679.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,511.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,385.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,260.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,448.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,260.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,448.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,385.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,679.87 ","$6,511.01 ",
"Acute Myocardial Infarction, Expired W MCC",283,MS-DRG,100,RC,,,inpatient,,,,,,"$4,654.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,654.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,235.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,077.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,919.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,156.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,919.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,156.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,077.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,654.69 ","$8,235.81 ",
"Acute Myocardial Infarction, Expired W CC",284,MS-DRG,100,RC,,,inpatient,,,,,,"$2,211.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,211.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,912.56 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,837.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,762.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,874.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,762.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,874.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,837.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,211.29 ","$3,912.56 ",
"Acute Myocardial Infarction, Expired W/O CC/MCC",285,MS-DRG,100,RC,,,inpatient,,,,,,"$2,151.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,151.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,807.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,734.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,660.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,770.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,660.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,770.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,734.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,151.86 ","$3,807.40 ",
"Circulatory Disorders Except Ami, W Card Cath W MCC",286,MS-DRG,100,RC,,,inpatient,,,,,,"$9,632.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,632.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,043.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,715.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,387.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,879.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,387.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,879.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,715.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,632.34 ","$17,043.03 ",
"Circulatory Disorders Except Ami, W Card Cath W/O MCC",287,MS-DRG,100,RC,,,inpatient,,,,,,"$4,981.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,981.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,814.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,644.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,475.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,729.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,475.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,729.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,644.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,981.75 ","$8,814.49 ",
Acute & Subacute Endocarditis W MCC,288,MS-DRG,100,RC,,,inpatient,,,,,,"$7,834.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,834.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,861.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,595.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,328.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,728.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,328.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,728.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,595.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,834.45 ","$13,861.93 ",
Acute & Subacute Endocarditis W CC,289,MS-DRG,100,RC,,,inpatient,,,,,,"$5,014.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,014.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,872.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,702.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,531.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,787.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,531.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,787.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,702.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,014.65 ","$8,872.69 ",
Acute & Subacute Endocarditis W/O CC/MCC,290,MS-DRG,100,RC,,,inpatient,,,,,,"$4,588.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,588.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,118.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,962.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,806.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,040.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,806.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,040.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,962.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,588.54 ","$8,118.75 ",
Heart Failure & Shock W MCC,291,MS-DRG,100,RC,,,inpatient,,,,,,"$5,169.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,169.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,145.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,969.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,794.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,057.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,794.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,057.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,969.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,169.02 ","$9,145.83 ",
Heart Failure & Shock W CC,292,MS-DRG,100,RC,,,inpatient,,,,,,"$3,334.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,334.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,900.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,787.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,673.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,843.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,673.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,843.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,787.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,334.87 ","$5,900.58 ",
Heart Failure & Shock W/O CC/MCC,293,MS-DRG,100,RC,,,inpatient,,,,,,"$2,314.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,314.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,095.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,016.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,938.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,056.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,938.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,056.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,016.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,314.83 ","$4,095.75 ",
Deep Vein Thrombophlebitis W CC/MCC,294,MS-DRG,100,RC,,,inpatient,,,,,,"$2,924.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,924.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,173.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,074.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,974.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,974.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,074.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,924.09 ","$5,173.75 ",
Deep Vein Thrombophlebitis W/O CC/MCC,295,MS-DRG,100,RC,,,inpatient,,,,,,"$2,924.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,924.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,173.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,074.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,974.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,974.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,074.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,924.09 ","$5,173.75 ",
"Cardiac Arrest, Unexplained W MCC",296,MS-DRG,100,RC,,,inpatient,,,,,,"$6,426.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,426.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,369.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,151.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,932.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,260.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,932.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,260.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,151.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,426.04 ","$11,369.96 ",
"Cardiac Arrest, Unexplained W CC",297,MS-DRG,100,RC,,,inpatient,,,,,,"$1,809.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,809.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,200.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,139.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,077.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,170.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,077.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,170.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,139.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,809.10 ","$3,200.94 ",
"Cardiac Arrest, Unexplained W/O CC/MCC",298,MS-DRG,100,RC,,,inpatient,,,,,,"$1,809.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,809.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,200.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,139.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,077.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,170.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,077.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,170.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,139.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,809.10 ","$3,200.94 ",
Peripheral Vascular Disorders W MCC,299,MS-DRG,100,RC,,,inpatient,,,,,,"$4,686.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,686.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,292.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,132.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,973.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,212.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,973.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,212.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,132.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,686.47 ","$8,292.03 ",
Peripheral Vascular Disorders W CC,300,MS-DRG,100,RC,,,inpatient,,,,,,"$3,861.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,861.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,831.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,700.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,569.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,766.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,569.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,766.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,700.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,861.16 ","$6,831.76 ",
Peripheral Vascular Disorders W/O CC/MCC,301,MS-DRG,100,RC,,,inpatient,,,,,,"$2,218.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,218.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,925.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,850.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,774.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,888.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,774.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,888.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,850.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,218.76 ","$3,925.78 ",
Atherosclerosis W MCC,302,MS-DRG,100,RC,,,inpatient,,,,,,"$2,775.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,775.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,910.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,816.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,721.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,863.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,721.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,863.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,816.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,775.32 ","$4,910.54 ",
Atherosclerosis W/O MCC,303,MS-DRG,100,RC,,,inpatient,,,,,,"$2,665.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,665.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,715.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,624.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,534.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,670.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,534.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,670.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,624.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,665.06 ","$4,715.44 ",
Hypertension W MCC,304,MS-DRG,100,RC,,,inpatient,,,,,,"$3,302.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,302.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,843.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,731.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,787.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,787.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,731.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,302.73 ","$5,843.70 ",
Hypertension W/O MCC,305,MS-DRG,100,RC,,,inpatient,,,,,,"$2,702.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,702.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,782.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,690.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,598.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,736.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,598.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,736.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,690.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,702.81 ","$4,782.23 ",
Cardiac Congenital & Valvular Disorders Age >17 W MCC,306,MS-DRG,100,RC,,,inpatient,,,,,,"$3,356.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,356.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,938.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,824.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,710.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,881.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,710.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,881.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,824.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,356.55 ","$5,938.94 ",
Cardiac Congenital & Valvular Disorders Age >17 W/O MCC,307,MS-DRG,100,RC,,,inpatient,,,,,,"$2,607.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,607.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,612.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,524.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,435.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,568.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,435.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,568.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,524.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,607.12 ","$4,612.93 ",
Cardiac Arrhythmia & Conduction Disorders W MCC,308,MS-DRG,100,RC,,,inpatient,,,,,,"$5,034.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,034.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,908.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,737.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,565.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,822.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,565.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,822.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,737.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,034.83 ","$8,908.41 ",
Cardiac Arrhythmia & Conduction Disorders W CC,309,MS-DRG,100,RC,,,inpatient,,,,,,"$3,221.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,221.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,700.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,591.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,481.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,646.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,481.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,646.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,591.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,221.99 ","$5,700.85 ",
Cardiac Arrhythmia & Conduction Disorders W/O CC/MCC,310,MS-DRG,100,RC,,,inpatient,,,,,,"$2,179.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,179.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,856.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,782.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,708.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,819.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,708.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,819.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,782.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,179.52 ","$3,856.34 ",
Angina Pectoris,311,MS-DRG,100,RC,,,inpatient,,,,,,"$2,731.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,731.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,833.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,740.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,647.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,787.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,647.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,787.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,740.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,731.97 ","$4,833.82 ",
Syncope & Collapse,312,MS-DRG,100,RC,,,inpatient,,,,,,"$2,852.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,852.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,047.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,950.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,853.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,998.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,853.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,998.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,950.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,852.70 ","$5,047.44 ",
Chest Pain,313,MS-DRG,100,RC,,,inpatient,,,,,,"$2,794.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,794.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,944.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,849.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,754.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,897.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,754.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,897.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,849.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,794.76 ","$4,944.93 ",
Other Circulatory System Diagnoses W MCC,314,MS-DRG,100,RC,,,inpatient,,,,,,"$8,716.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,716.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,422.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,126.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,829.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,274.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,829.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,274.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,126.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,716.57 ","$15,422.72 ",
Other Circulatory System Diagnoses W CC,315,MS-DRG,100,RC,,,inpatient,,,,,,"$4,286.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,286.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,584.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,438.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,292.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,511.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,292.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,511.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,438.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,286.52 ","$7,584.38 ",
Other Circulatory System Diagnoses W/O CC/MCC,316,MS-DRG,100,RC,,,inpatient,,,,,,"$3,284.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,284.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,810.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,698.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,587.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,754.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,587.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,754.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,698.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,284.04 ","$5,810.64 ",
Endovascular Cardiac Valve Replacement W MCC,317,MS-DRG,100,RC,,,inpatient,,,,,,"$21,947.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$21,947.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,832.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,085.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,339.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,459.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,339.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,459.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$38,085.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$21,947.30 ","$38,832.58 ",
Endovascular Cardiac Valve Replacement W/O MCC,318,MS-DRG,100,RC,,,inpatient,,,,,,"$17,532.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,532.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,022.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,425.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,828.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,723.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,828.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,723.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$30,425.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,532.95 ","$31,022.02 ",
"Stomach, Esophageal & Duodenal Proc Age >17 W MCC",326,MS-DRG,100,RC,,,inpatient,,,,,,"$17,477.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,477.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,924.14 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,329.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,734.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,626.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,734.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,626.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$30,329.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,477.63 ","$30,924.14 ",
"Stomach, Esophageal & Duodenal Proc Age >17 W CC",327,MS-DRG,100,RC,,,inpatient,,,,,,"$8,742.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,742.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,469.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,171.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,874.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,320.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,874.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,320.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,171.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,742.74 ","$15,469.01 ",
"Stomach, Esophageal & Duodenal Proc Age >17 W/O CC/MCC",328,MS-DRG,100,RC,,,inpatient,,,,,,"$5,315.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,315.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,405.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,224.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,043.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,315.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,043.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,315.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,224.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,315.91 ","$9,405.74 ",
Major Small & Large Bowel Procedures W MCC,329,MS-DRG,100,RC,,,inpatient,,,,,,"$18,224.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,224.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,246.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,626.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,005.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,936.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,005.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,936.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,626.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,224.81 ","$32,246.18 ",
Major Small & Large Bowel Procedures W CC,330,MS-DRG,100,RC,,,inpatient,,,,,,"$9,443.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,443.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,709.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,388.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,067.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,549.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,067.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,549.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,388.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,443.95 ","$16,709.71 ",
Major Small & Large Bowel Procedures W/O CC/MCC,331,MS-DRG,100,RC,,,inpatient,,,,,,"$6,301.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,301.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,149.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,935.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,720.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,042.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,720.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,042.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,935.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,301.57 ","$11,149.73 ",
Rectal Resection W MCC,332,MS-DRG,100,RC,,,inpatient,,,,,,"$13,373.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,373.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,662.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,207.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,752.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,434.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,752.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,434.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,207.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,373.51 ","$23,662.50 ",
Rectal Resection W CC,333,MS-DRG,100,RC,,,inpatient,,,,,,"$7,359.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,359.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,022.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,771.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,521.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,896.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,521.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,896.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,771.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,359.75 ","$13,022.01 ",
Rectal Resection W/O CC/MCC,334,MS-DRG,100,RC,,,inpatient,,,,,,"$5,700.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,700.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,085.61 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,891.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,697.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,988.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,697.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,988.63 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,891.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,700.16 ","$10,085.61 ",
Peritoneal Adhesiolysis W MCC,335,MS-DRG,100,RC,,,inpatient,,,,,,"$18,121.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,121.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,062.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,446.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,829.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,754.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,829.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,754.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,446.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,121.28 ","$32,062.99 ",
Peritoneal Adhesiolysis W CC,336,MS-DRG,100,RC,,,inpatient,,,,,,"$9,208.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,208.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,293.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,980.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,667.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,137.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,667.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,137.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,980.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,208.84 ","$16,293.72 ",
Peritoneal Adhesiolysis W/O CC/MCC,337,MS-DRG,100,RC,,,inpatient,,,,,,"$5,630.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,630.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,961.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,770.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,578.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,866.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,578.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,866.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,770.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,630.26 ","$9,961.94 ",
Appendectomy W Complicated Principal Diag W MCC,338,MS-DRG,100,RC,,,inpatient,,,,,,"$8,383.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,383.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,832.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,547.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,262.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,690.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,262.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,690.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,547.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,383.16 ","$14,832.79 ",
Appendectomy W Complicated Principal Diag W CC,339,MS-DRG,100,RC,,,inpatient,,,,,,"$6,317.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,317.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,178.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,963.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,748.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,070.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,748.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,070.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,963.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,317.65 ","$11,178.16 ",
Appendectomy W Complicated Principal Diag W/O CC/MCC,340,MS-DRG,100,RC,,,inpatient,,,,,,"$4,947.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,947.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,754.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,585.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,417.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,670.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,417.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,670.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,585.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,947.74 ","$8,754.31 ",
Appendectomy W/O Complicated Principal Diag W MCC,341,MS-DRG,100,RC,,,inpatient,,,,,,"$7,431.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,431.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,149.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,896.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,643.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,023.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,643.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,023.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,896.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,431.89 ","$13,149.65 ",
Appendectomy W/O Complicated Principal Diag W CC,342,MS-DRG,100,RC,,,inpatient,,,,,,"$4,152.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,152.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,346.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,205.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,064.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,276.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,064.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,276.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,205.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,152.33 ","$7,346.95 ",
Appendectomy W/O Complicated Principal Diag W/O CC/MCC,343,MS-DRG,100,RC,,,inpatient,,,,,,"$3,304.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,304.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,847.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,735.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,622.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,791.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,622.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,791.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,735.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,304.97 ","$5,847.67 ",
Minor Small & Large Bowel Procedures W MCC,344,MS-DRG,100,RC,,,inpatient,,,,,,"$9,640.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,640.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,057.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,729.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,401.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,893.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,401.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,893.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,729.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,640.56 ","$17,057.58 ",
Minor Small & Large Bowel Procedures W CC,345,MS-DRG,100,RC,,,inpatient,,,,,,"$5,070.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,070.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,971.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,798.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,626.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,884.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,626.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,884.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,798.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,070.34 ","$8,971.23 ",
Minor Small & Large Bowel Procedures W/O CC/MCC,346,MS-DRG,100,RC,,,inpatient,,,,,,"$3,613.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,613.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,393.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,270.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,147.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,331.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,147.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,331.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,270.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,613.34 ","$6,393.29 ",
Anal & Stomal Procedures W MCC,347,MS-DRG,100,RC,,,inpatient,,,,,,"$4,471.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,471.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,912.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,760.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,608.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,836.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,608.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,836.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,760.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,471.92 ","$7,912.41 ",
Anal & Stomal Procedures W CC,348,MS-DRG,100,RC,,,inpatient,,,,,,"$4,219.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,219.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,466.00 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,322.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,178.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,394.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,178.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,394.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,322.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,219.61 ","$7,466.00 ",
Anal & Stomal Procedures W/O CC/MCC,349,MS-DRG,100,RC,,,inpatient,,,,,,"$2,898.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,898.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,128.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,030.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,931.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,079.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,931.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,079.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,030.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,898.67 ","$5,128.78 ",
Inguinal & Femoral Hernia Procedures Age >17 W MCC,350,MS-DRG,100,RC,,,inpatient,,,,,,"$7,542.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,542.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,344.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,088.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,831.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,216.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,831.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,216.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,088.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,542.15 ","$13,344.75 ",
Inguinal & Femoral Hernia Procedures Age >17 W CC,351,MS-DRG,100,RC,,,inpatient,,,,,,"$4,786.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,786.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,468.61 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,305.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,142.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,387.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,142.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,387.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,305.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,786.27 ","$8,468.61 ",
Inguinal & Femoral Hernia Procedures Age >17 W/O CC/MCC,352,MS-DRG,100,RC,,,inpatient,,,,,,"$2,977.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,977.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,268.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,167.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,065.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,217.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,065.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,217.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,167.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,977.54 ","$5,268.33 ",
Hernia Procedures Except Inguinal & Femoral Age >17 W MCC,353,MS-DRG,100,RC,,,inpatient,,,,,,"$8,343.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,343.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,762.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,478.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,194.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,620.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,194.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,620.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,478.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,343.17 ","$14,762.03 ",
Hernia Procedures Except Inguinal & Femoral Age >17 W CC,354,MS-DRG,100,RC,,,inpatient,,,,,,"$5,976.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,976.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,575.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,371.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,168.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,473.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,168.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,473.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,371.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,976.76 ","$10,575.01 ",
Hernia Procedures Except Inguinal & Femoral Age >17 W/O CC/MCC,355,MS-DRG,100,RC,,,inpatient,,,,,,"$4,222.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,222.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,471.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,328.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,184.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,400.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,184.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,400.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,328.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,222.98 ","$7,471.95 ",
Other Digestive System O.R. Procedures W MCC,356,MS-DRG,100,RC,,,inpatient,,,,,,"$13,253.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,253.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,450.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,999.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,548.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,225.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,548.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,225.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,999.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,253.90 ","$23,450.87 ",
Other Digestive System O.R. Procedures W CC,357,MS-DRG,100,RC,,,inpatient,,,,,,"$6,126.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,126.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,840.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,631.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,423.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,735.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,423.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,735.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,631.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,126.64 ","$10,840.21 ",
Other Digestive System O.R. Procedures W/O CC/MCC,358,MS-DRG,100,RC,,,inpatient,,,,,,"$5,601.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,601.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,911.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,720.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,529.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,815.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,529.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,815.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,720.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,601.48 ","$9,911.02 ",
Major Esophageal Disorders W MCC,368,MS-DRG,100,RC,,,inpatient,,,,,,"$5,298.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,298.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,374.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,194.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,014.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,284.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,014.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,284.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,194.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,298.35 ","$9,374.66 ",
Major Esophageal Disorders W CC,369,MS-DRG,100,RC,,,inpatient,,,,,,"$4,310.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,310.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,627.37 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,480.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,334.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,554.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,334.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,554.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,480.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,310.82 ","$7,627.37 ",
Major Esophageal Disorders W/O CC/MCC,370,MS-DRG,100,RC,,,inpatient,,,,,,"$2,174.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,174.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,847.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,773.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,699.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,810.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,699.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,810.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,773.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,174.66 ","$3,847.74 ",
Major Gastrointestinal Disorders & Peritoneal Infections W MCC,371,MS-DRG,100,RC,,,inpatient,,,,,,"$6,415.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,415.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,352.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,133.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,915.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,242.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,915.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,242.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,133.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,415.95 ","$11,352.10 ",
Major Gastrointestinal Disorders & Peritoneal Infections W CC,372,MS-DRG,100,RC,,,inpatient,,,,,,"$3,762.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,762.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,656.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,528.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,400.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,592.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,400.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,592.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,528.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,762.11 ","$6,656.50 ",
Major Gastrointestinal Disorders & Peritoneal Infections W/O CC/MCC,373,MS-DRG,100,RC,,,inpatient,,,,,,"$2,951.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,951.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,222.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,122.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,021.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,172.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,021.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,172.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,122.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,951.75 ","$5,222.69 ",
Digestive Malignancy W MCC,374,MS-DRG,100,RC,,,inpatient,,,,,,"$6,282.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,282.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,115.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,901.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,687.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,008.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,687.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,008.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,901.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,282.14 ","$11,115.34 ",
Digestive Malignancy W CC,375,MS-DRG,100,RC,,,inpatient,,,,,,"$4,837.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,837.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,559.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,394.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,230.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,476.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,230.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,476.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,394.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,837.47 ","$8,559.21 ",
Digestive Malignancy W/O CC/MCC,376,MS-DRG,100,RC,,,inpatient,,,,,,"$3,011.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,011.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,329.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,226.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,277.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,124.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,277.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,226.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,011.93 ","$5,329.17 ",
G.I. Hemorrhage W MCC,377,MS-DRG,100,RC,,,inpatient,,,,,,"$6,078.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,078.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,754.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,547.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,340.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,650.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,340.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,650.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,547.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,078.05 ","$10,754.24 ",
G.I. Hemorrhage W CC,378,MS-DRG,100,RC,,,inpatient,,,,,,"$3,686.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,686.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,523.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,398.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,272.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,460.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,272.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,460.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,398.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,686.98 ","$6,523.57 ",
G.I. Hemorrhage W/O CC/MCC,379,MS-DRG,100,RC,,,inpatient,,,,,,"$2,964.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,964.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,245.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,144.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,043.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,043.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,144.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,964.46 ","$5,245.18 ",
Complicated Peptic Ulcer W MCC,380,MS-DRG,100,RC,,,inpatient,,,,,,"$4,753.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,753.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,410.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,248.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,086.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,329.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,086.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,329.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,248.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,753.37 ","$8,410.41 ",
Complicated Peptic Ulcer W CC,381,MS-DRG,100,RC,,,inpatient,,,,,,"$3,631.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,631.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,425.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,302.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,178.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,363.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,178.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,363.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,302.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,631.66 ","$6,425.69 ",
Complicated Peptic Ulcer W/O CC/MCC,382,MS-DRG,100,RC,,,inpatient,,,,,,"$2,722.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,722.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,817.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,725.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,632.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,771.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,632.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,771.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,725.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,722.99 ","$4,817.95 ",
Uncomplicated Peptic Ulcer W MCC,383,MS-DRG,100,RC,,,inpatient,,,,,,"$4,161.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,161.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,363.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,221.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,080.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,292.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,080.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,292.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,221.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,161.68 ","$7,363.49 ",
Uncomplicated Peptic Ulcer W/O MCC,384,MS-DRG,100,RC,,,inpatient,,,,,,"$2,985.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,985.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,282.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,180.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,079.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,231.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,079.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,231.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,180.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,985.39 ","$5,282.22 ",
Inflammatory Bowel Disease W MCC,385,MS-DRG,100,RC,,,inpatient,,,,,,"$4,194.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,194.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,422.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,279.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,136.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,350.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,136.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,350.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,279.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,194.94 ","$7,422.35 ",
Inflammatory Bowel Disease W CC,386,MS-DRG,100,RC,,,inpatient,,,,,,"$3,925.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,925.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,945.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,811.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,678.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,878.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,678.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,878.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,811.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,925.45 ","$6,945.51 ",
Inflammatory Bowel Disease W/O CC/MCC,387,MS-DRG,100,RC,,,inpatient,,,,,,"$3,166.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,166.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,602.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,495.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,387.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,549.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,387.47 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,549.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,495.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,166.67 ","$5,602.97 ",
G.I. Obstruction W MCC,388,MS-DRG,100,RC,,,inpatient,,,,,,"$4,610.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,610.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,158.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,001.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,844.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,079.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,844.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,079.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,001.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,610.96 ","$8,158.43 ",
G.I. Obstruction W CC,389,MS-DRG,100,RC,,,inpatient,,,,,,"$3,138.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,138.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,553.37 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,446.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,339.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,499.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,339.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,499.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,446.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,138.64 ","$5,553.37 ",
G.I. Obstruction W/O CC/MCC,390,MS-DRG,100,RC,,,inpatient,,,,,,"$2,198.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,198.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,890.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,815.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,741.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,853.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,741.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,853.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,815.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,198.95 ","$3,890.73 ",
"Esophagitis, Gastroent & Misc Digest Disorders Age >17 W MCC",391,MS-DRG,100,RC,,,inpatient,,,,,,"$4,127.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,127.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,302.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,162.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,021.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,232.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,021.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,232.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,162.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,127.29 ","$7,302.64 ",
"Esophagitis, Gastroent & Misc Digest Disorders Age >17 W/O MCC",392,MS-DRG,100,RC,,,inpatient,,,,,,"$2,783.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,783.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,925.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,830.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,735.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,877.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,735.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,877.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,830.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,783.55 ","$4,925.09 ",
Other Digestive System Diagnoses Age >17 W MCC,393,MS-DRG,100,RC,,,inpatient,,,,,,"$4,688.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,688.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,295.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,136.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,976.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,216.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,976.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,216.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,136.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,688.71 ","$8,295.99 ",
Other Digestive System Diagnoses Age >17 W CC,394,MS-DRG,100,RC,,,inpatient,,,,,,"$3,710.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,710.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,564.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,438.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,312.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,501.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,312.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,501.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,438.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,710.15 ","$6,564.58 ",
Other Digestive System Diagnoses Age >17 W/O CC/MCC,395,MS-DRG,100,RC,,,inpatient,,,,,,"$2,510.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,510.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,442.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,356.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,271.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,399.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,271.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,399.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,356.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,510.69 ","$4,442.30 ",
"Pancreas, Liver & Shunt Procedures W MCC",405,MS-DRG,100,RC,,,inpatient,,,,,,"$14,572.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,572.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,784.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,288.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,792.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,536.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,792.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,536.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,288.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,572.60 ","$25,784.11 ",
"Pancreas, Liver & Shunt Procedures W CC",406,MS-DRG,100,RC,,,inpatient,,,,,,"$10,463.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,463.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,513.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,157.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,801.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,335.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,801.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,335.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,157.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,463.63 ","$18,513.88 ",
"Pancreas, Liver & Shunt Procedures W/O CC/MCC",407,MS-DRG,100,RC,,,inpatient,,,,,,"$7,698.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,698.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,620.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,358.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,096.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,489.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,096.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,489.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,358.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,698.02 ","$13,620.54 ",
Biliary Tract Proc Except Only Cholecyst W or W/O C.D.E. W MCC,408,MS-DRG,100,RC,,,inpatient,,,,,,"$11,536.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,536.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,411.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,018.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,626.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,215.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,626.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,215.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,018.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,536.00 ","$20,411.29 ",
Biliary Tract Proc Except Only Cholecyst W or W/O C.D.E. W CC,409,MS-DRG,100,RC,,,inpatient,,,,,,"$7,442.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,442.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,168.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,914.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,661.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,041.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,661.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,041.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,914.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,442.35 ","$13,168.17 ",
Biliary Tract Proc Except Only Cholecyst W or W/O C.D.E. W/O CC/MCC,410,MS-DRG,100,RC,,,inpatient,,,,,,"$5,246.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,246.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,282.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,103.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,925.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,192.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,925.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,192.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,103.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,246.02 ","$9,282.07 ",
Cholecystectomy W C.D.E. W MCC,411,MS-DRG,100,RC,,,inpatient,,,,,,"$13,878.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,878.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,555.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,083.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,611.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,319.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,611.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,319.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$24,083.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,878.49 ","$24,555.98 ",
Cholecystectomy W C.D.E. W CC,412,MS-DRG,100,RC,,,inpatient,,,,,,"$7,088.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,088.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,541.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,300.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,059.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,421.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,059.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,421.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,300.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,088.38 ","$12,541.87 ",
Cholecystectomy W C.D.E. W/O CC/MCC,413,MS-DRG,100,RC,,,inpatient,,,,,,"$5,232.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,232.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,258.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,080.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,902.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,169.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,902.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,169.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,080.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,232.93 ","$9,258.92 ",
Cholecystectomy Except By Laparoscope W/O C.D.E. W MCC,414,MS-DRG,100,RC,,,inpatient,,,,,,"$13,626.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,626.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,110.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,646.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,182.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,878.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,182.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,878.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,646.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,626.56 ","$24,110.23 ",
Cholecystectomy Except By Laparoscope W/O C.D.E. W CC,415,MS-DRG,100,RC,,,inpatient,,,,,,"$6,591.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,591.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,662.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,438.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,213.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,550.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,213.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,550.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,438.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,591.25 ","$11,662.27 ",
Cholecystectomy Except By Laparoscope W/O C.D.E. W/O CC/MCC,416,MS-DRG,100,RC,,,inpatient,,,,,,"$3,508.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,508.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,207.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,088.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,968.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,147.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,968.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,147.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,088.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,508.31 ","$6,207.45 ",
Laparoscopic Cholecystectomy W/O C.D.E. W MCC,417,MS-DRG,100,RC,,,inpatient,,,,,,"$8,334.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,334.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,747.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,463.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,180.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,605.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,180.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,605.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,463.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,334.94 ","$14,747.48 ",
Laparoscopic Cholecystectomy W/O C.D.E. W CC,418,MS-DRG,100,RC,,,inpatient,,,,,,"$5,654.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,654.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,004.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,811.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,619.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,908.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,619.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,908.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,811.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,654.19 ","$10,004.27 ",
Laparoscopic Cholecystectomy W/O C.D.E. W/O CC/MCC,419,MS-DRG,100,RC,,,inpatient,,,,,,"$4,442.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,442.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,860.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,709.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,557.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,784.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,557.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,784.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,709.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,442.39 ","$7,860.16 ",
Hepatobiliary Diagnostic Procedures W MCC,420,MS-DRG,100,RC,,,inpatient,,,,,,"$12,763.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,763.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,582.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,148.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,713.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,365.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,713.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,365.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,148.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,763.13 ","$22,582.51 ",
Hepatobiliary Diagnostic Procedures W CC,421,MS-DRG,100,RC,,,inpatient,,,,,,"$5,090.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,090.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,006.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,833.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,659.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,919.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,659.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,919.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,833.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,090.15 ","$9,006.29 ",
Hepatobiliary Diagnostic Procedures W/O CC/MCC,422,MS-DRG,100,RC,,,inpatient,,,,,,"$4,513.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,513.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,985.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,832.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,678.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,909.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,678.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,909.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,832.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,513.41 ","$7,985.82 ",
Other Hepatobiliary or Pancreas O.R. Procedures W MCC,423,MS-DRG,100,RC,,,inpatient,,,,,,"$12,043.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,043.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,309.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,899.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,489.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,104.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,489.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,104.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,899.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,043.60 ","$21,309.41 ",
Other Hepatobiliary or Pancreas O.R. Procedures W CC,424,MS-DRG,100,RC,,,inpatient,,,,,,"$6,858.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,858.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,134.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,901.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,667.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,017.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,667.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,017.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,901.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,858.13 ","$12,134.48 ",
Other Hepatobiliary or Pancreas O.R. Procedures W/O CC/MCC,425,MS-DRG,100,RC,,,inpatient,,,,,,"$6,740.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,740.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,926.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,696.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,467.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,811.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,467.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,811.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,696.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,740.39 ","$11,926.15 ",
Cirrhosis & Alcoholic Hepatitis W MCC,432,MS-DRG,100,RC,,,inpatient,,,,,,"$7,003.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,003.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,391.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,153.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,915.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,272.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,915.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,272.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,153.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,003.53 ","$12,391.74 ",
Cirrhosis & Alcoholic Hepatitis W CC,433,MS-DRG,100,RC,,,inpatient,,,,,,"$3,524.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,524.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,235.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,115.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,996.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,175.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,996.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,175.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,115.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,524.38 ","$6,235.88 ",
Cirrhosis & Alcoholic Hepatitis W/O CC/MCC,434,MS-DRG,100,RC,,,inpatient,,,,,,"$2,452.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,452.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,338.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,255.03 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,171.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,296.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,171.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,296.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,255.03 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,452.00 ","$4,338.47 ",
Malignancy of Hepatobiliary System or Pancreas W MCC,435,MS-DRG,100,RC,,,inpatient,,,,,,"$5,347.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,347.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,461.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,279.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,097.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,370.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,097.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,370.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,279.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,347.31 ","$9,461.30 ",
Malignancy of Hepatobiliary System or Pancreas W CC,436,MS-DRG,100,RC,,,inpatient,,,,,,"$3,937.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,937.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,966.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,832.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,698.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,899.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,698.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,899.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,832.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,937.04 ","$6,966.02 ",
Malignancy of Hepatobiliary System or Pancreas W/O CC/MCC,437,MS-DRG,100,RC,,,inpatient,,,,,,"$3,092.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,092.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,471.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,366.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,260.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,418.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,260.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,418.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,366.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,092.29 ","$5,471.36 ",
Disorders of Pancreas Except Malignancy W MCC,438,MS-DRG,100,RC,,,inpatient,,,,,,"$6,614.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,614.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,703.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,478.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,253.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,590.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,253.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,590.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,478.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,614.43 ","$11,703.28 ",
Disorders of Pancreas Except Malignancy W CC,439,MS-DRG,100,RC,,,inpatient,,,,,,"$3,358.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,358.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,942.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,828.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,714.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,885.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,714.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,885.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,828.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,358.80 ","$5,942.91 ",
Disorders of Pancreas Except Malignancy W/O CC/MCC,440,MS-DRG,100,RC,,,inpatient,,,,,,"$2,459.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,459.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,351.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,268.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,184.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,309.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,184.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,309.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,268.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,459.48 ","$4,351.69 ",
"Disorders of Liver Except Malig,Cirr,Alc Hepa W MCC",441,MS-DRG,100,RC,,,inpatient,,,,,,"$6,794.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,794.59 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,022.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,790.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,559.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,906.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,559.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,906.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,790.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,794.59 ","$12,022.05 ",
"Disorders of Liver Except Malig,Cirr,Alc Hepa W CC",442,MS-DRG,100,RC,,,inpatient,,,,,,"$4,093.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,093.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,243.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,103.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,964.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,173.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,964.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,173.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,103.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,093.65 ","$7,243.12 ",
"Disorders of Liver Except Malig,Cirr,Alc Hepa W/O CC/MCC",443,MS-DRG,100,RC,,,inpatient,,,,,,"$2,546.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,546.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,505.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,419.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,332.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,462.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,332.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,462.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,419.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,546.57 ","$4,505.79 ",
Disorders of the Biliary Tract W MCC,444,MS-DRG,100,RC,,,inpatient,,,,,,"$5,711.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,711.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,106.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,911.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,717.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,008.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,717.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,008.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,911.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,711.75 ","$10,106.11 ",
Disorders of the Biliary Tract W CC,445,MS-DRG,100,RC,,,inpatient,,,,,,"$4,149.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,149.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,341.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,200.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,059.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,271.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,059.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,271.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,200.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,149.34 ","$7,341.66 ",
Disorders of the Biliary Tract W/O CC/MCC,446,MS-DRG,100,RC,,,inpatient,,,,,,"$2,633.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,633.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,659.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,569.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,480.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,614.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,480.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,614.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,569.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,633.29 ","$4,659.22 ",
Combined Anterior/Posterior Spinal Fusion W MCC,453,MS-DRG,100,RC,,,inpatient,,,,,,"$34,126.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$34,126.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$60,382.06 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$59,220.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,059.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$59,801.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,059.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$59,801.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$59,220.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$34,126.58 ","$60,382.06 ",
Combined Anterior/Posterior Spinal Fusion W CC,454,MS-DRG,100,RC,,,inpatient,,,,,,"$19,934.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$19,934.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,270.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,592.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,913.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,931.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,913.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,931.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$34,592.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$19,934.11 ","$35,270.54 ",
Combined Anterior/Posterior Spinal Fusion W/O CC/MCC,455,MS-DRG,100,RC,,,inpatient,,,,,,"$18,347.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,347.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,463.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,839.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,215.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,151.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,215.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,151.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,839.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,347.79 ","$32,463.77 ",
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec or Ext Fus W MCC,456,MS-DRG,100,RC,,,inpatient,,,,,,"$41,889.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$41,889.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$74,117.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$72,692.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$71,266.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$73,405.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$71,266.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$73,405.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$72,692.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$41,889.64 ","$74,117.67 ",
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec or Ext Fus W CC,457,MS-DRG,100,RC,,,inpatient,,,,,,"$29,387.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$29,387.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,997.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,997.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,997.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,497.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,997.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$51,497.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$50,997.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$29,387.78 ","$51,997.45 ",
Spinal Fus Exc Cerv W Spinal Curv/Malig/Infec or Ext Fus W/O CC/MCC,458,MS-DRG,100,RC,,,inpatient,,,,,,"$28,200.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$28,200.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,896.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$48,937.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$47,977.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,417.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$47,977.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,417.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$48,937.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$28,200.66 ","$49,896.99 ",
Spinal Fusion Except Cervical W MCC,459,MS-DRG,100,RC,,,inpatient,,,,,,"$33,635.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$33,635.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$59,512.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,367.92 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$57,223.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,940.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$57,223.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$58,940.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$58,367.92 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$33,635.06 ","$59,512.39 ",
Spinal Fusion Except Cervical W/O MCC,460,MS-DRG,100,RC,,,inpatient,,,,,,"$15,021.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,021.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,577.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,066.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,555.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,322.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,555.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,322.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$26,066.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,021.14 ","$26,577.74 ",
Bilateral or Multiple Major Joint Procs of Lower Extremity W MCC,461,MS-DRG,100,RC,,,inpatient,,,,,,"$14,931.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,931.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,419.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,911.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,403.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,165.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,403.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,165.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,911.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,931.80 ","$26,419.67 ",
Bilateral or Multiple Major Joint Procs of Lower Extremity W/O MCC,462,MS-DRG,100,RC,,,inpatient,,,,,,"$14,931.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,931.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,419.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,911.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,403.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,165.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,403.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,165.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,911.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,931.80 ","$26,419.67 ",
"Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis W MCC",463,MS-DRG,100,RC,,,inpatient,,,,,,"$21,592.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$21,592.21 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,204.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,469.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,734.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,836.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,734.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,836.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$37,469.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$21,592.21 ","$38,204.30 ",
"Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis W CC",464,MS-DRG,100,RC,,,inpatient,,,,,,"$11,254.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,254.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,913.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,530.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,147.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,721.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,147.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,721.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,530.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,254.55 ","$19,913.30 ",
"Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis W/O CC/MCC",465,MS-DRG,100,RC,,,inpatient,,,,,,"$5,484.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,484.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,704.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,518.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,331.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,611.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,331.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,611.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,518.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,484.86 ","$9,704.67 ",
Revision of Hip or Knee Replacement W MCC,466,MS-DRG,100,RC,,,inpatient,,,,,,"$12,138.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,138.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,476.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,063.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,650.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,270.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,650.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,270.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$21,063.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,138.16 ","$21,476.73 ",
Revision of Hip or Knee Replacement W CC,467,MS-DRG,100,RC,,,inpatient,,,,,,"$11,003.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,003.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,469.53 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,095.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,720.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,282.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,720.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,282.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,095.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,003.74 ","$19,469.53 ",
Revision of Hip or Knee Replacement W/O CC/MCC,468,MS-DRG,100,RC,,,inpatient,,,,,,"$8,832.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,832.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,628.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,327.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,027.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,478.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,027.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,478.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,327.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,832.82 ","$15,628.40 ",
Major Hip And Knee Joint Replacement or Reattachment of Lower Extremity W Mc,469,MS-DRG,100,RC,,,inpatient,,,,,,"$10,764.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,764.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,046.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,680.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,314.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,863.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,314.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,863.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,680.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,764.89 ","$19,046.93 ",
Major Hip And Knee Joint Replacement or Reattachment of Lower Extremity W/O,470,MS-DRG,100,RC,,,inpatient,,,,,,"$8,103.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,103.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,338.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,063.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,787.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,200.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,787.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,200.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,063.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,103.95 ","$14,338.76 ",
Cervical Spinal Fusion W MCC,471,MS-DRG,100,RC,,,inpatient,,,,,,"$12,637.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,637.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,360.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,930.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,500.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,145.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,500.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,145.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$21,930.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,637.54 ","$22,360.30 ",
Cervical Spinal Fusion W CC,472,MS-DRG,100,RC,,,inpatient,,,,,,"$9,762.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,762.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,273.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,941.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,608.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,107.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,608.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,107.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,941.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,762.41 ","$17,273.18 ",
Cervical Spinal Fusion W/O CC/MCC,473,MS-DRG,100,RC,,,inpatient,,,,,,"$7,570.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,570.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,394.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,136.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,879.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,265.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,879.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,265.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,136.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,570.19 ","$13,394.35 ",
Amputation for Musculoskeletal Sys & Conn Tissue Dis W MCC,474,MS-DRG,100,RC,,,inpatient,,,,,,"$13,063.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,063.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,113.58 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,669.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,224.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,891.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,224.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,891.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,669.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,063.27 ","$23,113.58 ",
Amputation for Musculoskeletal Sys & Conn Tissue Dis W CC,475,MS-DRG,100,RC,,,inpatient,,,,,,"$8,271.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,271.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,635.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,353.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,072.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,494.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,072.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,494.33 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,353.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,271.40 ","$14,635.05 ",
Amputation for Musculoskeletal Sys & Conn Tissue Dis W/O CC/MCC,476,MS-DRG,100,RC,,,inpatient,,,,,,"$3,585.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,585.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,343.68 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,221.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,099.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,282.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,099.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,282.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,221.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,585.31 ","$6,343.68 ",
Biopsies of Musculoskeletal System & Connective Tissue W MCC,477,MS-DRG,100,RC,,,inpatient,,,,,,"$10,515.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,515.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,606.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,248.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,890.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,427.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,890.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,427.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,248.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,515.95 ","$18,606.47 ",
Biopsies of Musculoskeletal System & Connective Tissue W CC,478,MS-DRG,100,RC,,,inpatient,,,,,,"$8,414.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,414.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,887.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,601.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,315.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,744.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,315.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,744.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,601.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,414.18 ","$14,887.69 ",
Biopsies of Musculoskeletal System & Connective Tissue W/O CC/MCC,479,MS-DRG,100,RC,,,inpatient,,,,,,"$6,323.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,323.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,188.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,973.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,758.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,081.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,758.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,081.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,973.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,323.63 ","$11,188.75 ",
Hip & Femur Procedures Except Major Joint Age >17 W MCC,480,MS-DRG,100,RC,,,inpatient,,,,,,"$14,381.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,381.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,446.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,957.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,468.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,202.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,468.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,202.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$24,957.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,381.97 ","$25,446.83 ",
Hip & Femur Procedures Except Major Joint Age >17 W CC,481,MS-DRG,100,RC,,,inpatient,,,,,,"$8,745.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,745.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,474.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,176.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,879.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,325.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,879.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,325.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,176.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,745.73 ","$15,474.30 ",
Hip & Femur Procedures Except Major Joint Age >17 W/O CC/MCC,482,MS-DRG,100,RC,,,inpatient,,,,,,"$6,198.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,198.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,967.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,756.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,545.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,861.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,545.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,861.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,756.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,198.41 ","$10,967.19 ",
Major Joint/Limb Reattachment Procedure of Upper Extremities,483,MS-DRG,100,RC,,,inpatient,,,,,,"$8,631.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,631.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,272.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,978.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,685.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,125.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,685.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,125.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,978.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,631.72 ","$15,272.59 ",
Knee Procedures W Pdx of Infection W MCC,485,MS-DRG,100,RC,,,inpatient,,,,,,"$7,603.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,603.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,453.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,195.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,936.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,324.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,936.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,324.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,195.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,603.83 ","$13,453.88 ",
Knee Procedures W Pdx of Infection W CC,486,MS-DRG,100,RC,,,inpatient,,,,,,"$7,053.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,053.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,479.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,239.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,999.72 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,359.71 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,999.72 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,359.71 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,239.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,053.25 ","$12,479.70 ",
Knee Procedures W Pdx of Infection W/O CC/MCC,487,MS-DRG,100,RC,,,inpatient,,,,,,"$3,869.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,869.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,846.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,714.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,582.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,780.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,582.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,780.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,714.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,869.38 ","$6,846.31 ",
Knee Procedures W/O Pdx of Infection W CC/MCC,488,MS-DRG,100,RC,,,inpatient,,,,,,"$5,648.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,648.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,995.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,802.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,610.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,898.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,610.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,898.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,802.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,648.95 ","$9,995.01 ",
Knee Procedures W/O Pdx of Infection W/O CC/MCC,489,MS-DRG,100,RC,,,inpatient,,,,,,"$5,045.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,045.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,927.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,755.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,584.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,841.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,584.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,841.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,755.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,045.67 ","$8,927.59 ",
"Lower Extrem & Humer Proc Except Hip,Foot,Femur Age >17 W MCC",492,MS-DRG,100,RC,,,inpatient,,,,,,"$11,875.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,875.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,012.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,608.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,204.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,810.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,204.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,810.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$20,608.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,875.77 ","$21,012.46 ",
"Lower Extrem & Humer Proc Except Hip,Foot,Femur Age >17 W CC",493,MS-DRG,100,RC,,,inpatient,,,,,,"$8,000.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,000.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,156.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,884.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,611.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,020.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,611.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,020.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,884.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,000.78 ","$14,156.23 ",
"Lower Extrem & Humer Proc Except Hip,Foot,Femur Age >17 W/O CC/MCC",494,MS-DRG,100,RC,,,inpatient,,,,,,"$5,856.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,856.40 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,362.06 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,162.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,963.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,262.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,963.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,262.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,162.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,856.40 ","$10,362.06 ",
Local Excision & Removal Int Fix Devices Exc Hip & Femur W MCC,495,MS-DRG,100,RC,,,inpatient,,,,,,"$9,587.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,587.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,964.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,638.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,311.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,801.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,311.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,801.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,638.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,587.86 ","$16,964.33 ",
Local Excision & Removal Int Fix Devices Exc Hip & Femur W CC,496,MS-DRG,100,RC,,,inpatient,,,,,,"$5,376.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,376.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,512.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,329.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,147.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,421.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,147.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,421.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,329.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,376.47 ","$9,512.88 ",
Local Excision & Removal Int Fix Devices Exc Hip & Femur W/O CC/MCC,497,MS-DRG,100,RC,,,inpatient,,,,,,"$4,280.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,280.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,573.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,428.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,282.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,500.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,282.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,500.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,428.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,280.54 ","$7,573.80 ",
Local Excision & Removal Int Fix Devices of Hip & Femur W CC/MCC,498,MS-DRG,100,RC,,,inpatient,,,,,,"$6,952.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,952.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,301.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,065.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,828.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,183.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,828.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,183.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,065.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,952.70 ","$12,301.80 ",
Local Excision & Removal Int Fix Devices of Hip & Femur W/O CC/MCC,499,MS-DRG,100,RC,,,inpatient,,,,,,"$3,730.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,730.71 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,600.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,474.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,347.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,537.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,347.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,537.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,474.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,730.71 ","$6,600.95 ",
Soft Tissue Procedures W MCC,500,MS-DRG,100,RC,,,inpatient,,,,,,"$8,670.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,670.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,341.37 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,046.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,751.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,193.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,751.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,193.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,046.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,670.60 ","$15,341.37 ",
Soft Tissue Procedures W CC,501,MS-DRG,100,RC,,,inpatient,,,,,,"$6,634.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,634.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,738.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,512.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,286.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,625.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,286.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,625.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,512.59 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,634.24 ","$11,738.33 ",
Soft Tissue Procedures W/O CC/MCC,502,MS-DRG,100,RC,,,inpatient,,,,,,"$4,931.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,931.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,725.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,558.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,390.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,641.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,390.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,641.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,558.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,931.67 ","$8,725.87 ",
Foot Procedures W MCC,503,MS-DRG,100,RC,,,inpatient,,,,,,"$6,435.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,435.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,385.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,166.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,947.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,276.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,947.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,276.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,166.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,435.01 ","$11,385.83 ",
Foot Procedures W CC,504,MS-DRG,100,RC,,,inpatient,,,,,,"$5,606.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,606.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,920.27 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,729.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,538.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,824.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,538.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,824.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,729.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,606.72 ","$9,920.27 ",
Foot Procedures W/O CC/MCC,505,MS-DRG,100,RC,,,inpatient,,,,,,"$5,407.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,407.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,567.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,383.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,199.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,475.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,199.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,475.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,383.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,407.49 ","$9,567.77 ",
Major Thumb or Joint Procedures,506,MS-DRG,100,RC,,,inpatient,,,,,,"$3,940.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,940.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,971.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,837.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,703.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,904.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,703.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,904.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,837.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,940.03 ","$6,971.31 ",
Major Shoulder or Elbow Joint Procedures W CC/MCC,507,MS-DRG,100,RC,,,inpatient,,,,,,"$5,593.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,593.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,896.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,706.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,515.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,801.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,515.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,801.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,706.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,593.26 ","$9,896.47 ",
Major Shoulder or Elbow Joint Procedures W/O CC/MCC,508,MS-DRG,100,RC,,,inpatient,,,,,,"$4,714.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,714.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,341.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,181.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,020.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,261.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,020.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,261.42 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,181.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,714.50 ","$8,341.63 ",
Arthroscopy,509,MS-DRG,100,RC,,,inpatient,,,,,,"$7,704.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,704.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,632.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,370.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,108.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,501.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,108.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,501.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,370.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,704.75 ","$13,632.44 ",
"Shoulder,Elbow or forearm Proc,Exc Major Joint Proc W MCC",510,MS-DRG,100,RC,,,inpatient,,,,,,"$7,982.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,982.09 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,123.16 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,851.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,579.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,987.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,579.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,987.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,851.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,982.09 ","$14,123.16 ",
"Shoulder,Elbow or forearm Proc,Exc Major Joint Proc W CC",511,MS-DRG,100,RC,,,inpatient,,,,,,"$5,862.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,862.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,372.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,173.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,973.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,272.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,973.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,272.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,173.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,862.38 ","$10,372.64 ",
"Shoulder,Elbow or forearm Proc,Exc Major Joint Proc W/O CC/MCC",512,MS-DRG,100,RC,,,inpatient,,,,,,"$3,862.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,862.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,833.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,702.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,570.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,768.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,570.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,768.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,702.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,862.28 ","$6,833.75 ",
"Hand or Wrist Proc, Except Major Thumb or Joint Proc W CC/MCC",513,MS-DRG,100,RC,,,inpatient,,,,,,"$4,952.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,952.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,762.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,593.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,425.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,677.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,425.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,677.99 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,593.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,952.22 ","$8,762.25 ",
"Hand or Wrist Proc, Except Major Thumb or Joint Proc W/O CC/MCC",514,MS-DRG,100,RC,,,inpatient,,,,,,"$4,068.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,068.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,199.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,061.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,922.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,130.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,922.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,130.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,061.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,068.98 ","$7,199.47 ",
Other Musculoskelet Sys & Conn Tiss O.R. Proc W MCC,515,MS-DRG,100,RC,,,inpatient,,,,,,"$13,615.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,615.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,091.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,627.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,164.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,859.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,164.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,859.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,627.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,615.72 ","$24,091.05 ",
Other Musculoskelet Sys & Conn Tiss O.R. Proc W CC,516,MS-DRG,100,RC,,,inpatient,,,,,,"$8,133.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,133.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,391.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,114.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,837.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,252.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,837.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,252.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,114.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,133.47 ","$14,391.01 ",
Other Musculoskelet Sys & Conn Tiss O.R. Proc W/O CC/MCC,517,MS-DRG,100,RC,,,inpatient,,,,,,"$7,505.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,505.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,279.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,024.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,769.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,152.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,769.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,152.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,024.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,505.52 ","$13,279.94 ",
Back & Neck Proc Exc Spinal Fusion W MCC or Disc Device/Neurostim,518,MS-DRG,100,RC,,,inpatient,,,,,,"$8,823.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,823.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,611.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,311.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,011.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,461.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,011.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,461.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,311.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,823.47 ","$15,611.87 ",
Back & Neck Proc Exc Spinal Fusion W CC,519,MS-DRG,100,RC,,,inpatient,,,,,,"$7,484.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,484.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,242.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,987.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,732.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,114.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,732.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,114.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,987.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,484.22 ","$13,242.24 ",
Back & Neck Proc Exc Spinal Fusion W/O CC/MCC,520,MS-DRG,100,RC,,,inpatient,,,,,,"$4,073.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,073.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,207.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,068.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,930.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,138.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,930.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,138.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,068.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,073.47 ","$7,207.41 ",
Fractures of Femur W MCC,533,MS-DRG,100,RC,,,inpatient,,,,,,"$3,399.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,399.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,015.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,899.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,784.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,957.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,784.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,957.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,899.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,399.91 ","$6,015.65 ",
Fractures of Femur W/O MCC,534,MS-DRG,100,RC,,,inpatient,,,,,,"$1,792.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,792.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,171.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,110.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,049.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,140.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,049.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,140.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,110.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,792.28 ","$3,171.18 ",
Fractures of Hip & Pelvis W MCC,535,MS-DRG,100,RC,,,inpatient,,,,,,"$3,189.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,189.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,643.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,534.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,426.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,589.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,426.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,589.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,534.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,189.47 ","$5,643.31 ",
Fractures of Hip & Pelvis W/O MCC,536,MS-DRG,100,RC,,,inpatient,,,,,,"$2,721.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,721.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,815.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,722.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,630.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,769.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,630.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,769.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,722.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,721.50 ","$4,815.30 ",
"Sprains, Strains, & Dislocations of Hip, Pelvis & Thigh W CC/MCC",537,MS-DRG,100,RC,,,inpatient,,,,,,"$2,561.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,561.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,532.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,445.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,357.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,488.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,357.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,488.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,445.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,561.52 ","$4,532.24 ",
"Sprains, Strains, & Dislocations of Hip, Pelvis & Thigh W/O CC/MCC",538,MS-DRG,100,RC,,,inpatient,,,,,,"$1,924.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,924.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,405.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,340.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,274.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,373.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,274.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,373.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,340.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,924.97 ","$3,405.96 ",
Osteomyelitis W MCC,539,MS-DRG,100,RC,,,inpatient,,,,,,"$6,722.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,722.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,894.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,665.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,436.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,780.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,436.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,780.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,665.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,722.45 ","$11,894.41 ",
Osteomyelitis W CC,540,MS-DRG,100,RC,,,inpatient,,,,,,"$4,851.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,851.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,584.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,419.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,254.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,501.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,254.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,501.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,419.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,851.68 ","$8,584.34 ",
Osteomyelitis W/O CC/MCC,541,MS-DRG,100,RC,,,inpatient,,,,,,"$2,717.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,717.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,808.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,716.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,623.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,762.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,623.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,762.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,716.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,717.76 ","$4,808.69 ",
Pathological Fractures & Musculoskelet & Conn Tiss Malig W MCC,542,MS-DRG,100,RC,,,inpatient,,,,,,"$5,495.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,495.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,723.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,536.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,349.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,630.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,349.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,630.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,536.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,495.70 ","$9,723.85 ",
Pathological Fractures & Musculoskelet & Conn Tiss Malig W CC,543,MS-DRG,100,RC,,,inpatient,,,,,,"$5,359.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,359.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,483.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,300.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,118.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,391.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,118.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,391.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,300.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,359.65 ","$9,483.12 ",
Pathological Fractures & Musculoskelet & Conn Tiss Malig W/O CC/MCC,544,MS-DRG,100,RC,,,inpatient,,,,,,"$2,358.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,358.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,173.13 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,092.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,012.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,133.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,012.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,133.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,092.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,358.56 ","$4,173.13 ",
Connective Tissue Disorders W MCC,545,MS-DRG,100,RC,,,inpatient,,,,,,"$8,488.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,488.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,019.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,730.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,441.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,874.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,441.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,874.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,730.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,488.57 ","$15,019.29 ",
Connective Tissue Disorders W CC,546,MS-DRG,100,RC,,,inpatient,,,,,,"$4,443.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,443.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,861.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,710.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,559.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,785.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,559.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,785.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,710.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,443.13 ","$7,861.49 ",
Connective Tissue Disorders W/O CC/MCC,547,MS-DRG,100,RC,,,inpatient,,,,,,"$2,998.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,998.47 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,305.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,203.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,101.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,254.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,101.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,254.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,203.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,998.47 ","$5,305.36 ",
Septic Arthritis W MCC,548,MS-DRG,100,RC,,,inpatient,,,,,,"$5,010.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,010.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,865.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,694.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,524.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,780.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,524.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,780.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,694.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,010.53 ","$8,865.42 ",
Septic Arthritis W CC,549,MS-DRG,100,RC,,,inpatient,,,,,,"$5,010.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,010.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,865.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,694.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,524.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,780.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,524.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,780.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,694.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,010.53 ","$8,865.42 ",
Septic Arthritis W/O CC/MCC,550,MS-DRG,100,RC,,,inpatient,,,,,,"$2,827.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,827.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,003.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,906.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,810.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,955.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,810.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,955.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,906.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,827.65 ","$5,003.12 ",
Medical Back Problems W MCC,551,MS-DRG,100,RC,,,inpatient,,,,,,"$4,145.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,145.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,335.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,193.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,052.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,264.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,052.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,264.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,193.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,145.61 ","$7,335.05 ",
Medical Back Problems W/O MCC,552,MS-DRG,100,RC,,,inpatient,,,,,,"$3,370.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,370.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,964.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,849.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,734.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,906.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,734.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,906.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,849.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,370.76 ","$5,964.07 ",
Bone Diseases & Arthropathies W MCC,553,MS-DRG,100,RC,,,inpatient,,,,,,"$3,181.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,181.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,628.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,520.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,412.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,574.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,412.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,574.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,520.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,181.25 ","$5,628.76 ",
Bone Diseases & Arthropathies W/O MCC,554,MS-DRG,100,RC,,,inpatient,,,,,,"$2,978.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,978.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,269.65 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,168.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,066.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,218.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,066.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,218.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,168.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,978.29 ","$5,269.65 ",
Signs & Symptoms of Musculoskeletal System & Conn Tissue W MCC,555,MS-DRG,100,RC,,,inpatient,,,,,,"$4,272.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,272.32 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,559.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,413.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,268.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,486.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,268.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,486.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,413.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,272.32 ","$7,559.25 ",
Signs & Symptoms of Musculoskeletal System & Conn Tissue W/O MCC,556,MS-DRG,100,RC,,,inpatient,,,,,,"$2,828.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,828.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,003.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,907.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,811.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,955.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,811.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,955.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,907.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,828.03 ","$5,003.79 ",
"Tendonitis, Myositis & Bursitis W MCC",557,MS-DRG,100,RC,,,inpatient,,,,,,"$3,707.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,707.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,559.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,433.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,307.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,496.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,307.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,496.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,433.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,707.53 ","$6,559.95 ",
"Tendonitis, Myositis & Bursitis W/O MCC",558,MS-DRG,100,RC,,,inpatient,,,,,,"$2,913.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,913.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,154.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,055.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,956.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,105.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,956.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,105.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,055.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,913.25 ","$5,154.57 ",
"Aftercare, Musculoskeletal System & Connective Tissue W MCC",559,MS-DRG,100,RC,,,inpatient,,,,,,"$10,825.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,825.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,154.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,786.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,418.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,970.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,418.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,970.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,786.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,825.82 ","$19,154.73 ",
"Aftercare, Musculoskeletal System & Connective Tissue W CC",560,MS-DRG,100,RC,,,inpatient,,,,,,"$7,576.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,576.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,404.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,147.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,889.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,276.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,889.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,276.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,147.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,576.17 ","$13,404.94 ",
"Aftercare, Musculoskeletal System & Connective Tissue W/O CC/MCC",561,MS-DRG,100,RC,,,inpatient,,,,,,"$5,602.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,602.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,913.00 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,722.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,531.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,817.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,531.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,817.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,722.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,602.60 ","$9,913.00 ",
"Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh Age >17 W MCC",562,MS-DRG,100,RC,,,inpatient,,,,,,"$3,617.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,617.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,401.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,278.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,155.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,339.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,155.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,339.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,278.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,617.83 ","$6,401.22 ",
"Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh Age >17 W/O MCC",563,MS-DRG,100,RC,,,inpatient,,,,,,"$3,201.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,201.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,664.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,555.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,446.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,610.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,446.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,610.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,555.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,201.43 ","$5,664.48 ",
Other Musculoskeletal Sys & Connective Tissue Diagnoses W MCC,564,MS-DRG,100,RC,,,inpatient,,,,,,"$4,239.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,239.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,500.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,356.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,211.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,428.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,211.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,428.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,356.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,239.05 ","$7,500.39 ",
Other Musculoskeletal Sys & Connective Tissue Diagnoses W CC,565,MS-DRG,100,RC,,,inpatient,,,,,,"$4,239.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,239.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,500.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,356.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,211.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,428.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,211.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,428.27 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,356.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,239.05 ","$7,500.39 ",
Other Musculoskeletal Sys & Connective Tissue Diagnoses W/O CC/MCC,566,MS-DRG,100,RC,,,inpatient,,,,,,"$2,170.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,170.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,839.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,765.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,692.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,802.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,692.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,802.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,765.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,170.17 ","$3,839.81 ",
Skin Debridement W MCC,570,MS-DRG,100,RC,,,inpatient,,,,,,"$6,128.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,128.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,844.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,635.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,427.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,739.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,427.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,739.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,635.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,128.89 ","$10,844.18 ",
Skin Debridement W CC,571,MS-DRG,100,RC,,,inpatient,,,,,,"$4,554.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,554.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,058.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,903.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,748.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,981.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,748.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,981.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,903.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,554.52 ","$8,058.57 ",
Skin Debridement W/O CC/MCC,572,MS-DRG,100,RC,,,inpatient,,,,,,"$3,396.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,396.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,009.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,893.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,777.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,951.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,777.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,951.26 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,893.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,396.17 ","$6,009.04 ",
Skin Graft for Skin Ulcer or Cellulitis W MCC,573,MS-DRG,100,RC,,,inpatient,,,,,,"$10,361.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,361.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,333.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,981.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,628.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,157.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,628.84 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,157.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,981.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,361.96 ","$18,333.99 ",
Skin Graft for Skin Ulcer or Cellulitis W CC,574,MS-DRG,100,RC,,,inpatient,,,,,,"$8,160.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,160.76 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,439.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,161.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,883.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,300.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,883.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,300.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,161.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,160.76 ","$14,439.29 ",
Skin Graft for Skin Ulcer or Cellulitis W/O CC/MCC,575,MS-DRG,100,RC,,,inpatient,,,,,,"$5,360.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,360.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,484.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,302.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,119.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,393.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,119.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,393.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,302.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,360.39 ","$9,484.44 ",
Skin Graft Exc for Skin Ulcer or Cellulitis W MCC,576,MS-DRG,100,RC,,,inpatient,,,,,,"$19,069.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$19,069.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,740.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,091.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,443.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,416.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,443.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,416.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$33,091.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$19,069.56 ","$33,740.84 ",
Skin Graft Exc for Skin Ulcer or Cellulitis W CC,577,MS-DRG,100,RC,,,inpatient,,,,,,"$8,497.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,497.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,035.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,746.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,457.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,891.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,457.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,891.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,746.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,497.91 ","$15,035.83 ",
Skin Graft Exc for Skin Ulcer or Cellulitis W/O CC/MCC,578,MS-DRG,100,RC,,,inpatient,,,,,,"$5,604.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,604.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,915.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,724.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,534.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,820.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,534.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,820.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,724.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,604.10 ","$9,915.64 ",
"Other Skin, Subcut Tiss & Breast Proc W MCC",579,MS-DRG,100,RC,,,inpatient,,,,,,"$11,457.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,457.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,271.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,881.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,492.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,076.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,492.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,076.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,881.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,457.14 ","$20,271.75 ",
"Other Skin, Subcut Tiss & Breast Proc W CC",580,MS-DRG,100,RC,,,inpatient,,,,,,"$5,154.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,154.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,120.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,944.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,769.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,032.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,769.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,032.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,944.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,154.44 ","$9,120.04 ",
"Other Skin, Subcut Tiss & Breast Proc W/O CC/MCC",581,MS-DRG,100,RC,,,inpatient,,,,,,"$3,676.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,676.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,504.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,379.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,254.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,441.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,254.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,441.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,379.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,676.14 ","$6,504.39 ",
Mastectomy for Malignancy W CC/MCC,582,MS-DRG,100,RC,,,inpatient,,,,,,"$5,744.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,744.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,164.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,968.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,773.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,066.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,773.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,066.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,968.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,744.64 ","$10,164.31 ",
Mastectomy for Malignancy W/O CC/MCC,583,MS-DRG,100,RC,,,inpatient,,,,,,"$5,387.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,387.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,532.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,349.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,166.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,441.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,166.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,441.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,349.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,387.68 ","$9,532.72 ",
"Breast Biopsy, Local Excision & Other Breast Procedures W CC/MCC",584,MS-DRG,100,RC,,,inpatient,,,,,,"$6,396.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,396.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,317.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,100.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,882.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,208.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,882.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,208.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,100.06 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,396.51 ","$11,317.71 ",
"Breast Biopsy, Local Excision & Other Breast Procedures W/O CC/MCC",585,MS-DRG,100,RC,,,inpatient,,,,,,"$5,736.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,736.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,149.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,954.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,759.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,052.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,759.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,052.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,954.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,736.42 ","$10,149.76 ",
Skin Ulcers W MCC,592,MS-DRG,100,RC,,,inpatient,,,,,,"$5,393.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,393.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,543.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,359.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,176.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,451.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,176.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,451.54 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,359.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,393.66 ","$9,543.30 ",
Skin Ulcers W CC,593,MS-DRG,100,RC,,,inpatient,,,,,,"$3,792.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,792.01 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,709.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,580.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,451.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,644.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,451.36 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,644.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,580.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,792.01 ","$6,709.41 ",
Skin Ulcers W/O CC/MCC,594,MS-DRG,100,RC,,,inpatient,,,,,,"$1,880.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,880.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,326.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,262.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,198.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,294.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,198.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,294.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,262.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,880.12 ","$3,326.60 ",
Major Skin Disorders W MCC,595,MS-DRG,100,RC,,,inpatient,,,,,,"$5,562.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,562.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,841.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,652.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,463.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,746.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,463.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,746.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,652.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,562.24 ","$9,841.57 ",
Major Skin Disorders W/O MCC,596,MS-DRG,100,RC,,,inpatient,,,,,,"$3,356.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,356.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,938.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,824.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,710.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,881.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,710.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,881.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,824.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,356.55 ","$5,938.94 ",
Malignant Breast Disorders W MCC,597,MS-DRG,100,RC,,,inpatient,,,,,,"$4,591.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,591.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,124.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,967.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,811.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,045.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,811.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,045.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,967.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,591.53 ","$8,124.04 ",
Malignant Breast Disorders W CC,598,MS-DRG,100,RC,,,inpatient,,,,,,"$3,473.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,473.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,146.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,028.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,910.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,087.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,910.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,087.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,028.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,473.92 ","$6,146.60 ",
Malignant Breast Disorders W/O CC/MCC,599,MS-DRG,100,RC,,,inpatient,,,,,,"$3,473.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,473.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,146.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,028.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,910.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,087.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,910.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,087.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,028.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,473.92 ","$6,146.60 ",
Non-Malignant Breast Disorders W CC/MCC,600,MS-DRG,100,RC,,,inpatient,,,,,,"$3,437.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,437.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,082.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,965.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,848.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,023.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,848.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,023.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,965.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,437.66 ","$6,082.45 ",
Non-Malignant Breast Disorders W/O CC/MCC,601,MS-DRG,100,RC,,,inpatient,,,,,,"$2,570.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,570.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,547.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,460.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,372.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,503.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,372.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,503.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,460.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,570.12 ","$4,547.45 ",
Cellulitis Age >17 W MCC,602,MS-DRG,100,RC,,,inpatient,,,,,,"$5,104.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,104.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,032.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,858.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,684.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,945.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,684.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,945.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,858.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,104.73 ","$9,032.08 ",
Cellulitis Age >17 W/O MCC,603,MS-DRG,100,RC,,,inpatient,,,,,,"$3,302.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,302.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,843.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,730.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,786.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,618.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,786.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,730.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,302.36 ","$5,843.04 ",
"Trauma To the Skin, Subcut Tiss & Breast Age >17 W MCC",604,MS-DRG,100,RC,,,inpatient,,,,,,"$3,633.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,633.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,429.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,306.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,182.37 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,367.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,182.37 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,367.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,306.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,633.90 ","$6,429.66 ",
"Trauma To the Skin, Subcut Tiss & Breast Age >17 W/O MCC",605,MS-DRG,100,RC,,,inpatient,,,,,,"$2,607.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,607.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,612.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,524.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,435.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,568.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,435.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,568.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,524.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,607.12 ","$4,612.93 ",
Minor Skin Disorders W MCC,606,MS-DRG,100,RC,,,inpatient,,,,,,"$3,418.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,418.23 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,048.06 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,931.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,815.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,989.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,815.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,989.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,931.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,418.23 ","$6,048.06 ",
Minor Skin Disorders W/O MCC,607,MS-DRG,100,RC,,,inpatient,,,,,,"$2,590.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,590.68 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,583.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,495.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,407.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,539.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,407.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,539.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,495.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,590.68 ","$4,583.83 ",
Bpd & Oth Chronic Respiratory Diseases Arising In Perinatal Period,608,MS-DRG,100,RC,,,inpatient,,,,,,"$12,932.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,932.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,881.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,441.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,001.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,661.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,001.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,661.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,441.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,932.08 ","$22,881.44 ",
Other Respiratory Problems After Birth,609,MS-DRG,100,RC,,,inpatient,,,,,,"$3,937.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,937.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,966.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,832.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,698.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,899.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,698.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,899.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,832.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,937.04 ","$6,966.02 ",
"Neonate, Died W/In One Day of Birth",610,MS-DRG,100,RC,,,inpatient,,,,,,$858.95 ,100,,,other,Amerigroup DRG using base rate 3737.81,$858.95 ,100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,519.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,490.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,461.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,505.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,461.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,505.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$1,490.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,$858.95 ,"$1,519.79 ",
"Neonate, Transferred <5 Days Old",611,MS-DRG,100,RC,,,inpatient,,,,,,$978.18 ,100,,,other,Amerigroup DRG using base rate 3737.81,$978.18 ,100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,730.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,697.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,664.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,714.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,664.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,714.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$1,697.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,$978.18 ,"$1,730.76 ",
"Neonate, Birthwt <750G, Discharged Alive",612,MS-DRG,100,RC,,,inpatient,,,,,,"$74,606.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$74,606.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$132,005.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$129,467.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$126,928.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$130,736.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$126,928.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$130,736.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$129,467.21 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$74,606.69 ","$132,005.78 ",
"Neonate, Birthwt <750G, Died",613,MS-DRG,100,RC,,,inpatient,,,,,,"$19,924.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$19,924.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,254.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,576.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,898.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,915.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,898.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$34,915.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$34,576.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$19,924.77 ","$35,254.01 ",
Adrenal & Pituitary Procedures W CC/MCC,614,MS-DRG,100,RC,,,inpatient,,,,,,"$9,741.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,741.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,236.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,905.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,573.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,071.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,573.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,071.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,905.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,741.85 ","$17,236.81 ",
Adrenal & Pituitary Procedures W/O CC/MCC,615,MS-DRG,100,RC,,,inpatient,,,,,,"$4,792.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,792.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,479.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,316.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,153.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,397.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,153.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,397.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,316.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,792.25 ","$8,479.19 ",
"Amputat of Lower Limb for Endocrine,Nutrit,& Metabol Dis W MCC",616,MS-DRG,100,RC,,,inpatient,,,,,,"$12,130.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,130.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,462.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,050.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,637.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,256.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,637.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,256.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$21,050.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,130.31 ","$21,462.84 ",
"Amputat of Lower Limb for Endocrine,Nutrit,& Metabol Dis W CC",617,MS-DRG,100,RC,,,inpatient,,,,,,"$7,013.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,013.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,409.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,170.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,932.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,290.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,932.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,290.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,170.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,013.63 ","$12,409.60 ",
"Amputat of Lower Limb for Endocrine,Nutrit,& Metabol Dis W/O CC/MCC",618,MS-DRG,100,RC,,,inpatient,,,,,,"$4,958.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,958.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,774.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,605.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,436.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,689.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,436.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,689.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,605.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,958.95 ","$8,774.15 ",
O.R. Procedures for Obesity W MCC,619,MS-DRG,100,RC,,,inpatient,,,,,,"$10,263.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,263.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,160.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,810.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,461.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,985.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,461.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,985.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,810.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,263.65 ","$18,160.05 ",
O.R. Procedures for Obesity W CC,620,MS-DRG,100,RC,,,inpatient,,,,,,"$6,600.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,600.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,678.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,453.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,228.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,565.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,228.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,565.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,453.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,600.22 ","$11,678.15 ",
O.R. Procedures for Obesity W/O CC/MCC,621,MS-DRG,100,RC,,,inpatient,,,,,,"$5,309.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,309.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,394.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,213.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,033.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,304.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,033.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,304.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,213.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,309.56 ","$9,394.50 ",
"Skin Grafts & Wound Debrid for Endoc, Nutrit & Metab Dis W MCC",622,MS-DRG,100,RC,,,inpatient,,,,,,"$12,372.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,372.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,891.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,470.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,049.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,680.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,049.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,680.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$21,470.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,372.52 ","$21,891.40 ",
"Skin Grafts & Wound Debrid for Endoc, Nutrit & Metab Dis W CC",623,MS-DRG,100,RC,,,inpatient,,,,,,"$6,759.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,759.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,959.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,729.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,499.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,844.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,499.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,844.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,729.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,759.08 ","$11,959.22 ",
"Skin Grafts & Wound Debrid for Endoc, Nutrit & Metab Dis W/O CC/MCC",624,MS-DRG,100,RC,,,inpatient,,,,,,"$2,711.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,711.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,798.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,705.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,613.56 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,751.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,613.56 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,751.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,705.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,711.78 ","$4,798.11 ",
"Thyroid, Parathyroid & Thyroglossal Procedures W MCC",625,MS-DRG,100,RC,,,inpatient,,,,,,"$7,036.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,036.43 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,449.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,210.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,971.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,330.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,971.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,330.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,210.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,036.43 ","$12,449.94 ",
"Thyroid, Parathyroid & Thyroglossal Procedures W CC",626,MS-DRG,100,RC,,,inpatient,,,,,,"$5,947.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,947.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,524.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,321.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,119.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,422.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,119.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,422.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,321.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,947.98 ","$10,524.09 ",
"Thyroid, Parathyroid & Thyroglossal Procedures W/O CC/MCC",627,MS-DRG,100,RC,,,inpatient,,,,,,"$4,332.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,332.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,665.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,517.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,370.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,591.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,370.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,591.36 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,517.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,332.12 ","$7,665.07 ",
"Other Endocrine, Nutrit & Metab O.R. Proc W MCC",628,MS-DRG,100,RC,,,inpatient,,,,,,"$9,036.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,036.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,988.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,680.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,373.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,834.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,373.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,834.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,680.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,036.16 ","$15,988.17 ",
"Other Endocrine, Nutrit & Metab O.R. Proc W CC",629,MS-DRG,100,RC,,,inpatient,,,,,,"$9,036.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,036.16 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,988.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,680.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,373.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,834.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,373.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,834.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,680.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,036.16 ","$15,988.17 ",
"Other Endocrine, Nutrit & Metab O.R. Proc W/O CC/MCC",630,MS-DRG,100,RC,,,inpatient,,,,,,"$4,479.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,479.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,925.64 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,773.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,620.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,849.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,620.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,849.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,773.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,479.39 ","$7,925.64 ",
"Neonate, Birthwt 750-999G, Discharged Alive",631,MS-DRG,100,RC,,,inpatient,,,,,,"$45,917.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$45,917.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$81,243.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$79,681.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$78,118.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$80,462.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$78,118.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$80,462.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$79,681.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$45,917.13 ","$81,243.74 ",
"Neonate, Birthwt 750-999G, Died",632,MS-DRG,100,RC,,,inpatient,,,,,,"$22,924.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$22,924.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,562.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,781.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,001.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,172.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,001.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,172.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$39,781.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$22,924.74 ","$40,562.02 ",
"Neonate, Birthwt 1000-1499G, W Signif O.R. Proc, Discharged Alive",633,MS-DRG,100,RC,,,inpatient,,,,,,"$51,998.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$51,998.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$92,004.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,235.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,465.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,119.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,465.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,119.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$90,235.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$51,998.92 ","$92,004.59 ",
"Neonate, Birthwt 1000-1499G, W/O Signif O.R. Proc, Discharged Alive",634,MS-DRG,100,RC,,,inpatient,,,,,,"$23,054.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$23,054.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,791.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,007.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,222.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,399.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,222.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$40,399.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$40,007.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$23,054.44 ","$40,791.51 ",
"Neonate, Birthwt 1000-1499G, Died",635,MS-DRG,100,RC,,,inpatient,,,,,,"$28,283.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$28,283.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,043.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,081.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$48,119.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,562.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$48,119.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,562.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$49,081.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$28,283.63 ","$50,043.81 ",
"Neonate, Birthwt 1500-1999G, W Signif O.R. Proc, W Mult Major Prob",636,MS-DRG,100,RC,,,inpatient,,,,,,"$37,985.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$37,985.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$67,209.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$65,916.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,624.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$66,562.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,624.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$66,562.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$65,916.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$37,985.12 ","$67,209.19 ",
Diabetes W MCC,637,MS-DRG,100,RC,,,inpatient,,,,,,"$5,048.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,048.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,932.88 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,761.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,589.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,846.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,589.30 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,846.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,761.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,048.66 ","$8,932.88 ",
Diabetes W CC,638,MS-DRG,100,RC,,,inpatient,,,,,,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,213.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,946.52 ","$5,213.43 ",
Diabetes W/O CC/MCC,639,MS-DRG,100,RC,,,inpatient,,,,,,"$2,052.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,052.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,630.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,561.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,491.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,595.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,491.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,595.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,561.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,052.06 ","$3,630.82 ",
"Misc Disorders of Nutrition,Metabolism,Fluids/Electrolytes >17 W MCC",640,MS-DRG,100,RC,,,inpatient,,,,,,"$3,625.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,625.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,414.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,291.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,167.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,352.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,167.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,352.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,291.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,625.30 ","$6,414.45 ",
"Misc Disorders of Nutrition,Metabolism,Fluids/Electrolytes >17 W/O MCC",641,MS-DRG,100,RC,,,inpatient,,,,,,"$2,776.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,776.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,912.52 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,818.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,723.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,865.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,723.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,865.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,818.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,776.45 ","$4,912.52 ",
Inborn And Other Disorders of Metabolism,642,MS-DRG,100,RC,,,inpatient,,,,,,"$3,436.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,436.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,079.81 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,962.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,845.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,021.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,845.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,021.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,962.89 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,436.17 ","$6,079.81 ",
Endocrine Disorders W MCC,643,MS-DRG,100,RC,,,inpatient,,,,,,"$6,370.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,370.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,272.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,055.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,838.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,163.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,838.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,163.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,055.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,370.72 ","$11,272.08 ",
Endocrine Disorders W CC,644,MS-DRG,100,RC,,,inpatient,,,,,,"$3,379.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,379.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,979.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,864.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,749.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,921.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,749.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,921.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,864.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,379.35 ","$5,979.28 ",
Endocrine Disorders W/O CC/MCC,645,MS-DRG,100,RC,,,inpatient,,,,,,"$2,598.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,598.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,597.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,508.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,420.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,552.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,420.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,552.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,508.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,598.15 ","$4,597.05 ",
"Neonate, Birthwt 1500-1999G, W Signif O.R. Proc, W/O Mult Major Prob",646,MS-DRG,100,RC,,,inpatient,,,,,,"$28,723.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$28,723.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,822.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$49,844.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$48,867.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,333.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$48,867.52 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$50,333.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$49,844.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$28,723.57 ","$50,822.23 ",
"Neonate, Birthwt 1500-1999G, W/O Signif O.R. Proc, W Mult Major Prob",647,MS-DRG,100,RC,,,inpatient,,,,,,"$14,221.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,221.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,163.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,679.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,195.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,921.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,195.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,921.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$24,679.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,221.99 ","$25,163.77 ",
"Neonate, Birthwt 1500-1999G, W/O Signif O.R. Proc, W Major Prob",648,MS-DRG,100,RC,,,inpatient,,,,,,"$9,883.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,883.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,486.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,150.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,814.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,318.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,814.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,318.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,150.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,883.14 ","$17,486.80 ",
"Neonate, Birthwt 1500-1999G, W/O Signif O.R. Proc, W Minor Prob",649,MS-DRG,100,RC,,,inpatient,,,,,,"$8,372.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,372.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,814.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,529.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,244.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,671.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,244.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,671.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,529.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,372.69 ","$14,814.28 ",
"Neonate, Birthwt 1500-1999G, W/O Signif O.R. Proc, W Other Prob",650,MS-DRG,100,RC,,,inpatient,,,,,,"$5,444.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,444.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,632.59 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,447.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,262.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,539.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,262.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,539.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,447.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,444.12 ","$9,632.59 ",
"Neonate, Birthwt 2000-2499G, W Signif O.R. Proc, W Mult Major Prob",651,MS-DRG,100,RC,,,inpatient,,,,,,"$32,137.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$32,137.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,863.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$55,769.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$54,675.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,316.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$54,675.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,316.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$55,769.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$32,137.69 ","$56,863.01 ",
Kidney Transplant,652,MS-DRG,100,RC,,,inpatient,,,,,,"$51,633.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$51,633.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$91,357.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$89,600.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$87,844.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,479.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$87,844.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$90,479.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$89,600.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$51,633.36 ","$91,357.79 ",
Major Bladder Procedures W MCC,653,MS-DRG,100,RC,,,inpatient,,,,,,"$17,864.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,864.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,607.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,000.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,392.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,304.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,392.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,304.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$31,000.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,864.12 ","$31,607.98 ",
Major Bladder Procedures W CC,654,MS-DRG,100,RC,,,inpatient,,,,,,"$8,183.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,183.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,478.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,200.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,922.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,339.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,922.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,339.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,200.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,183.19 ","$14,478.97 ",
Major Bladder Procedures W/O CC/MCC,655,MS-DRG,100,RC,,,inpatient,,,,,,"$6,744.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,744.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,932.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,703.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,473.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,818.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,473.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,818.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,703.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,744.13 ","$11,932.77 ",
Kidney & Ureter Procedures for Neoplasm W MCC,656,MS-DRG,100,RC,,,inpatient,,,,,,"$10,173.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,173.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,000.01 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,653.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,307.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,826.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,307.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,826.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,653.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,173.20 ","$18,000.01 ",
Kidney & Ureter Procedures for Neoplasm W CC,657,MS-DRG,100,RC,,,inpatient,,,,,,"$8,888.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,888.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,726.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,424.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,122.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,575.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,122.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,575.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,424.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,888.51 ","$15,726.94 ",
Kidney & Ureter Procedures for Neoplasm W/O CC/MCC,658,MS-DRG,100,RC,,,inpatient,,,,,,"$6,645.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,645.45 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,758.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,532.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,305.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,645.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,305.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,645.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,532.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,645.45 ","$11,758.17 ",
Kidney & Ureter Procedures for Non-Neoplasm W MCC,659,MS-DRG,100,RC,,,inpatient,,,,,,"$9,396.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,396.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,625.06 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,305.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,985.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,465.20 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,985.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,465.20 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,305.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,396.11 ","$16,625.06 ",
Kidney & Ureter Procedures for Non-Neoplasm W CC,660,MS-DRG,100,RC,,,inpatient,,,,,,"$5,133.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,133.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,083.00 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,908.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,733.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,995.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,733.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,995.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,908.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,133.51 ","$9,083.00 ",
Kidney & Ureter Procedures for Non-Neoplasm W/O CC/MCC,661,MS-DRG,100,RC,,,inpatient,,,,,,"$4,554.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,554.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,057.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,902.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,747.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,980.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,747.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,980.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,902.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,554.15 ","$8,057.91 ",
Minor Bladder Procedures W MCC,662,MS-DRG,100,RC,,,inpatient,,,,,,"$12,815.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,815.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,675.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,239.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,802.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,457.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,802.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,457.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,239.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,815.46 ","$22,675.10 ",
Minor Bladder Procedures W CC,663,MS-DRG,100,RC,,,inpatient,,,,,,"$4,946.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,946.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,752.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,584.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,415.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,668.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,415.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,668.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,584.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,946.62 ","$8,752.33 ",
Minor Bladder Procedures W/O CC/MCC,664,MS-DRG,100,RC,,,inpatient,,,,,,"$3,804.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,804.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,731.90 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,602.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,472.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,667.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,472.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,667.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,602.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,804.72 ","$6,731.90 ",
Prostatectomy W MCC,665,MS-DRG,100,RC,,,inpatient,,,,,,"$9,725.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,725.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,207.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,876.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,545.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,041.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,545.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,041.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,876.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,725.03 ","$17,207.05 ",
Prostatectomy W CC,666,MS-DRG,100,RC,,,inpatient,,,,,,"$6,332.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,332.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,203.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,988.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,773.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,096.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,773.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,096.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,988.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,332.22 ","$11,203.96 ",
Prostatectomy W/O CC/MCC,667,MS-DRG,100,RC,,,inpatient,,,,,,"$3,720.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,720.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,582.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,455.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,329.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,519.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,329.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,519.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,455.85 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,720.24 ","$6,582.43 ",
Transurethral Procedures W MCC,668,MS-DRG,100,RC,,,inpatient,,,,,,"$9,308.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,308.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,470.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,153.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,836.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,311.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,836.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,311.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,153.56 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,308.64 ","$16,470.30 ",
Transurethral Procedures W CC,669,MS-DRG,100,RC,,,inpatient,,,,,,"$4,279.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,279.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,571.15 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,425.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,279.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,498.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,279.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,498.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,425.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,279.04 ","$7,571.15 ",
Transurethral Procedures W/O CC/MCC,670,MS-DRG,100,RC,,,inpatient,,,,,,"$2,882.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,882.97 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,101.00 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,002.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,904.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,051.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,904.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,051.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,002.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,882.97 ","$5,101.00 ",
Urethral Procedures Age >17 W CC/MCC,671,MS-DRG,100,RC,,,inpatient,,,,,,"$5,140.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,140.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,094.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,920.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,745.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,007.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,745.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,007.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,920.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,140.24 ","$9,094.91 ",
Urethral Procedures Age >17 W/O CC/MCC,672,MS-DRG,100,RC,,,inpatient,,,,,,"$4,479.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,479.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,924.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,772.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,620.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,848.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,620.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,848.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,772.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,479.02 ","$7,924.98 ",
Other Kidney & Urinary Tract Procedures W MCC,673,MS-DRG,100,RC,,,inpatient,,,,,,"$9,928.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,928.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,567.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,229.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,891.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,398.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,891.81 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,398.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,229.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,928.74 ","$17,567.48 ",
Other Kidney & Urinary Tract Procedures W CC,674,MS-DRG,100,RC,,,inpatient,,,,,,"$9,566.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,566.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,926.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,601.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,275.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,763.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,275.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,763.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,601.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,566.55 ","$16,926.63 ",
Other Kidney & Urinary Tract Procedures W/O CC/MCC,675,MS-DRG,100,RC,,,inpatient,,,,,,"$4,887.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,887.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,647.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,481.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,315.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,564.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,315.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,564.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,481.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,887.56 ","$8,647.83 ",
"Neonate, Birthwt 2000-2499G, W Signif O.R. Proc, W/O Mult Major Prob",676,MS-DRG,100,RC,,,inpatient,,,,,,"$15,948.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,948.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,219.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,676.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,133.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,947.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,133.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,947.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,676.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,948.86 ","$28,219.21 ",
"Neonate, Birthwt 2000-2499G, W/O Signif O.R. Proc, W Mult Major Prob",677,MS-DRG,100,RC,,,inpatient,,,,,,"$8,738.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,738.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,461.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,164.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,867.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,313.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,867.06 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,313.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,164.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,738.63 ","$15,461.74 ",
"Neonate, Birthwt 2000-2499G, W/O Signif O.R. Proc, W Major Prob",678,MS-DRG,100,RC,,,inpatient,,,,,,"$5,436.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,436.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,619.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,434.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,249.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,526.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,249.38 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,526.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,434.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,436.64 ","$9,619.36 ",
"Neonate, Birthwt 2000-2499G, W/O Signif O.R. Proc, W Minor Prob",679,MS-DRG,100,RC,,,inpatient,,,,,,"$3,642.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,642.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,444.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,320.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,196.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,382.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,196.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,382.90 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,320.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,642.50 ","$6,444.87 ",
"Neonate, Birthwt 2000-2499G, W/O Signif O.R. Proc, W Other Prob",680,MS-DRG,100,RC,,,inpatient,,,,,,"$2,184.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,184.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,864.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,789.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,715.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,827.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,715.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,827.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,789.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,184.00 ","$3,864.28 ",
"Neonate, Birthwt >2499G, W Signif O.R. Proc, W Mult Major Prob",681,MS-DRG,100,RC,,,inpatient,,,,,,"$36,889.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$36,889.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$65,270.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,014.92 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$62,759.72 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,642.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$62,759.72 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$64,642.51 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$64,014.92 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$36,889.19 ","$65,270.11 ",
Renal Failure W MCC,682,MS-DRG,100,RC,,,inpatient,,,,,,"$4,952.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,952.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,762.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,594.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,425.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,678.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,425.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,678.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,594.39 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,952.60 ","$8,762.91 ",
Renal Failure W CC,683,MS-DRG,100,RC,,,inpatient,,,,,,"$3,492.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,492.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,179.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,060.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,941.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,120.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,941.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,120.25 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,060.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,492.61 ","$6,179.67 ",
Renal Failure W/O CC/MCC,684,MS-DRG,100,RC,,,inpatient,,,,,,"$2,165.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,165.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,831.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,757.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,683.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,794.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,683.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,794.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,757.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,165.31 ","$3,831.21 ",
Admit for Renal Dialysis,685,MS-DRG,100,RC,,,inpatient,,,,,,"$1,930.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,930.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,416.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,350.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,285.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,383.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,285.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,383.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,350.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,930.95 ","$3,416.54 ",
Kidney & Urinary Tract Neoplasms W MCC,686,MS-DRG,100,RC,,,inpatient,,,,,,"$3,882.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,882.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,870.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,738.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,605.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,804.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,605.89 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,804.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,738.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,882.84 ","$6,870.12 ",
Kidney & Urinary Tract Neoplasms W CC,687,MS-DRG,100,RC,,,inpatient,,,,,,"$3,020.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,020.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,343.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,240.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,138.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,292.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,138.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,292.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,240.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,020.15 ","$5,343.72 ",
Kidney & Urinary Tract Neoplasms W/O CC/MCC,688,MS-DRG,100,RC,,,inpatient,,,,,,"$1,965.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,965.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,477.39 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,410.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,343.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,343.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,410.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,965.34 ","$3,477.39 ",
Kidney & Urinary Tract Infections Age >17 W MCC,689,MS-DRG,100,RC,,,inpatient,,,,,,"$4,119.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,119.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,288.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,147.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,007.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,218.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,007.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,218.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,147.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,119.07 ","$7,288.09 ",
Kidney & Urinary Tract Infections Age >17 W/O MCC,690,MS-DRG,100,RC,,,inpatient,,,,,,"$2,918.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,918.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,063.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,964.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,113.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,964.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,113.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,063.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,918.11 ","$5,163.17 ",
Urinary Stones W Esw Lithotripsy W CC/MCC,691,MS-DRG,100,RC,,,inpatient,,,,,,"$4,571.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,571.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,088.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,933.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,777.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,011.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,777.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,011.21 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,933.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,571.72 ","$8,088.99 ",
Urinary Stones W Esw Lithotripsy W/O CC/MCC,692,MS-DRG,100,RC,,,inpatient,,,,,,"$4,261.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,261.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,540.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,395.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,250.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,467.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,250.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,467.57 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,395.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,261.48 ","$7,540.07 ",
Urinary Stones W/O Esw Lithotripsy W MCC,693,MS-DRG,100,RC,,,inpatient,,,,,,"$3,573.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,573.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,323.18 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,201.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,079.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,262.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,079.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,262.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,201.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,573.72 ","$6,323.18 ",
Urinary Stones W/O Esw Lithotripsy W/O MCC,694,MS-DRG,100,RC,,,inpatient,,,,,,"$2,742.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,742.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,851.68 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,758.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,665.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,805.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,665.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,805.02 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,758.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,742.06 ","$4,851.68 ",
Kidney & Urinary Tract Signs & Symptoms Age >17 W MCC,695,MS-DRG,100,RC,,,inpatient,,,,,,"$3,605.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,605.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,379.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,256.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,134.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,318.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,134.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,318.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,256.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,605.49 ","$6,379.40 ",
Kidney & Urinary Tract Signs & Symptoms Age >17 W/O MCC,696,MS-DRG,100,RC,,,inpatient,,,,,,"$1,942.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,942.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,437.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,370.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,304.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,404.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,304.85 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,404.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,370.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,942.54 ","$3,437.04 ",
Urethral Stricture Age >17,697,MS-DRG,100,RC,,,inpatient,,,,,,"$2,274.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,274.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,023.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,946.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,868.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,984.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,868.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,984.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,946.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,274.08 ","$4,023.66 ",
Other Kidney & Urinary Tract Diagnoses Age >17 W MCC,698,MS-DRG,100,RC,,,inpatient,,,,,,"$5,171.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,171.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,149.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,973.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,797.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,061.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,797.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,061.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,973.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,171.26 ","$9,149.80 ",
Other Kidney & Urinary Tract Diagnoses Age >17 W CC,699,MS-DRG,100,RC,,,inpatient,,,,,,"$3,678.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,678.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,508.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,383.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,258.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,445.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,258.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,445.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,383.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,678.38 ","$6,508.36 ",
Other Kidney & Urinary Tract Diagnoses Age >17 W/O CC/MCC,700,MS-DRG,100,RC,,,inpatient,,,,,,"$2,602.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,602.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,604.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,515.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,427.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,560.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,427.24 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,560.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,515.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,602.26 ","$4,604.33 ",
Major Male Pelvic Procedures W CC/MCC,707,MS-DRG,100,RC,,,inpatient,,,,,,"$7,098.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,098.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,559.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,317.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,076.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,438.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,076.03 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,438.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,317.55 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,098.10 ","$12,559.07 ",
Major Male Pelvic Procedures W/O CC/MCC,708,MS-DRG,100,RC,,,inpatient,,,,,,"$4,308.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,308.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,622.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,476.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,329.56 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,549.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,329.56 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,549.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,476.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,308.20 ","$7,622.74 ",
Penis Procedures W CC/MCC,709,MS-DRG,100,RC,,,inpatient,,,,,,"$5,639.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,639.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,979.13 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,787.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,595.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,883.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,595.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,883.18 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,787.23 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,639.98 ","$9,979.13 ",
Penis Procedures W/O CC/MCC,710,MS-DRG,100,RC,,,inpatient,,,,,,"$3,597.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,597.64 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,365.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,243.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,120.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,304.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,120.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,304.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,243.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,597.64 ","$6,365.51 ",
Testes Procedures Age >17 W CC/MCC,711,MS-DRG,100,RC,,,inpatient,,,,,,"$6,962.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,962.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,318.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,081.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,844.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,199.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,844.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,199.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,081.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,962.04 ","$12,318.33 ",
Testes Procedures Age >17 W/O CC/MCC,712,MS-DRG,100,RC,,,inpatient,,,,,,"$4,048.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,048.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,163.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,026.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,888.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,094.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,888.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,094.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,026.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,048.80 ","$7,163.76 ",
Transurethral Prostatectomy W CC/MCC,713,MS-DRG,100,RC,,,inpatient,,,,,,"$5,040.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,040.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,918.99 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,747.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,575.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,833.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,575.95 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,833.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,747.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,040.81 ","$8,918.99 ",
Transurethral Prostatectomy W/O CC/MCC,714,MS-DRG,100,RC,,,inpatient,,,,,,"$2,949.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,949.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,218.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,118.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,018.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,168.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,018.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,168.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,118.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,949.51 ","$5,218.73 ",
Other Male Reproductive System O.R. Proc for Malignancy W CC/MCC,715,MS-DRG,100,RC,,,inpatient,,,,,,"$9,152.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,152.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,194.52 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,883.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,571.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,038.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,571.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,038.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,883.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,152.78 ","$16,194.52 ",
Other Male Reproductive System O.R. Proc for Malignancy W/O CC/MCC,716,MS-DRG,100,RC,,,inpatient,,,,,,"$8,283.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,283.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,656.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,374.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,092.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,515.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,092.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,515.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,374.36 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,283.36 ","$14,656.21 ",
Other Male Reproductive System O.R. Proc Exc Malignancy W CC/MCC,717,MS-DRG,100,RC,,,inpatient,,,,,,"$5,661.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,661.29 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,016.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,824.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,631.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,920.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,631.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,920.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,824.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,661.29 ","$10,016.83 ",
Other Male Reproductive System O.R. Proc Exc Malignancy W/O CC/MCC,718,MS-DRG,100,RC,,,inpatient,,,,,,"$5,243.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,243.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,278.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,099.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,921.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,188.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,921.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,188.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,099.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,243.77 ","$9,278.10 ",
"Malignancy, Male Reproductive System W MCC",722,MS-DRG,100,RC,,,inpatient,,,,,,"$7,306.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,306.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,927.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,678.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,430.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,803.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,430.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,803.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,678.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,306.30 ","$12,927.44 ",
"Malignancy, Male Reproductive System W CC",723,MS-DRG,100,RC,,,inpatient,,,,,,"$3,053.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,053.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,401.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,298.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,349.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,349.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,298.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,053.04 ","$5,401.92 ",
"Malignancy, Male Reproductive System W/O CC/MCC",724,MS-DRG,100,RC,,,inpatient,,,,,,"$3,053.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,053.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,401.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,298.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,349.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,194.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,349.98 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,298.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,053.04 ","$5,401.92 ",
Benign Prostatic Hypertrophy W MCC,725,MS-DRG,100,RC,,,inpatient,,,,,,"$2,970.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,970.81 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,256.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,155.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,054.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,205.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,054.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,205.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,155.34 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,970.81 ","$5,256.42 ",
Benign Prostatic Hypertrophy W/O MCC,726,MS-DRG,100,RC,,,inpatient,,,,,,"$2,132.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,132.05 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,772.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,699.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,627.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,736.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,627.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,736.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,699.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,132.05 ","$3,772.35 ",
Inflammation of the Male Reproductive System W MCC,727,MS-DRG,100,RC,,,inpatient,,,,,,"$3,460.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,460.84 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,123.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,005.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,887.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,064.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,887.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,064.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,005.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,460.84 ","$6,123.45 ",
Inflammation of the Male Reproductive System W/O MCC,728,MS-DRG,100,RC,,,inpatient,,,,,,"$3,110.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,110.61 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,503.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,397.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,292.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,450.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,292.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,450.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,397.93 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,110.61 ","$5,503.77 ",
Other Male Reproductive System Diagnoses W CC/MCC,729,MS-DRG,100,RC,,,inpatient,,,,,,"$3,232.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,232.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,718.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,608.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,498.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,663.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,498.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,663.72 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,608.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,232.08 ","$5,718.71 ",
Other Male Reproductive System Diagnoses W/O CC/MCC,730,MS-DRG,100,RC,,,inpatient,,,,,,"$2,024.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,024.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,581.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,512.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,546.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,443.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,546.78 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,512.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,024.02 ","$3,581.22 ",
"Pelvic Evisceration, Rad Hysterectomy & Rad Vulvectomy W CC/MCC",734,MS-DRG,100,RC,,,inpatient,,,,,,"$7,119.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,119.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,597.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,355.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,112.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,476.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,112.91 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,476.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,355.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,119.78 ","$12,597.43 ",
"Pelvic Evisceration, Rad Hysterectomy & Rad Vulvectomy W/O CC/MCC",735,MS-DRG,100,RC,,,inpatient,,,,,,"$4,712.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,712.63 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,338.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,177.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,017.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,258.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,017.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,258.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,177.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,712.63 ","$8,338.32 ",
Uterine & Adnexa Proc for Ovarian or Adnexal Malignancy W MCC,736,MS-DRG,100,RC,,,inpatient,,,,,,"$10,649.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,649.77 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,843.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,480.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,118.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,662.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,118.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,662.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,480.86 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,649.77 ","$18,843.23 ",
Uterine & Adnexa Proc for Ovarian or Adnexal Malignancy W CC,737,MS-DRG,100,RC,,,inpatient,,,,,,"$5,967.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,967.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,557.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,354.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,151.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,456.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,151.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,456.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,354.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,967.04 ","$10,557.82 ",
Uterine & Adnexa Proc for Ovarian or Adnexal Malignancy W/O CC/MCC,738,MS-DRG,100,RC,,,inpatient,,,,,,"$4,491.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,491.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,947.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,794.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,641.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,871.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,641.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,871.04 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,794.63 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,491.73 ","$7,947.46 ",
"Uterine,Adnexa Proc for Non-Ovarian/Adnexal Malig W MCC",739,MS-DRG,100,RC,,,inpatient,,,,,,"$9,580.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,580.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,951.10 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,625.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,299.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,788.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,299.14 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,788.11 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$16,625.12 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,580.38 ","$16,951.10 ",
"Uterine,Adnexa Proc for Non-Ovarian/Adnexal Malig W CC",740,MS-DRG,100,RC,,,inpatient,,,,,,"$6,710.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,710.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,873.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,644.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,416.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,759.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,416.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,759.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,644.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,710.49 ","$11,873.25 ",
"Uterine,Adnexa Proc for Non-Ovarian/Adnexal Malig W/O CC/MCC",741,MS-DRG,100,RC,,,inpatient,,,,,,"$3,641.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,641.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,442.89 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,318.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,195.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,380.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,195.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,380.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,318.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,641.37 ","$6,442.89 ",
Uterine & Adnexa Proc for Non-Malignancy W CC/MCC,742,MS-DRG,100,RC,,,inpatient,,,,,,"$4,390.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,390.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,767.57 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,618.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,468.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,692.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,468.82 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,692.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,618.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,390.06 ","$7,767.57 ",
Uterine & Adnexa Proc for Non-Malignancy W/O CC/MCC,743,MS-DRG,100,RC,,,inpatient,,,,,,"$3,315.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,315.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,865.53 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,752.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,639.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,809.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,639.93 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,809.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,752.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,315.06 ","$5,865.53 ",
"D&C, Conization, Laparoscopy & Tubal Interruption W CC/MCC",744,MS-DRG,100,RC,,,inpatient,,,,,,"$4,458.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,458.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,888.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,736.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,585.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,812.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,585.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,812.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,736.90 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,458.46 ","$7,888.60 ",
"D&C, Conization, Laparoscopy & Tubal Interruption W/O CC/MCC",745,MS-DRG,100,RC,,,inpatient,,,,,,"$2,860.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,860.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,061.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,963.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,866.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,866.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.66 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,963.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,860.55 ","$5,061.32 ",
"Vagina, Cervix & Vulva Procedures W CC/MCC",746,MS-DRG,100,RC,,,inpatient,,,,,,"$4,267.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,267.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,551.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,406.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,260.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,478.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,260.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,478.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,406.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,267.83 ","$7,551.31 ",
"Vagina, Cervix & Vulva Procedures W/O CC/MCC",747,MS-DRG,100,RC,,,inpatient,,,,,,"$3,161.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,161.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,593.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,486.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,378.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,539.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,378.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,539.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,486.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,161.44 ","$5,593.71 ",
Female Reproductive System Reconstructive Procedures,748,MS-DRG,100,RC,,,inpatient,,,,,,"$3,427.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,427.95 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,065.26 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,948.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,831.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,006.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,831.98 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,006.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,948.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,427.95 ","$6,065.26 ",
Other Female Reproductive System O.R. Procedures W CC/MCC,749,MS-DRG,100,RC,,,inpatient,,,,,,"$7,427.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,427.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,142.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,889.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,636.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,016.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,636.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,016.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,889.64 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,427.78 ","$13,142.38 ",
Other Female Reproductive System O.R. Procedures W/O CC/MCC,750,MS-DRG,100,RC,,,inpatient,,,,,,"$4,020.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,020.39 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,113.50 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,976.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,839.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,045.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,839.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,045.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,976.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,020.39 ","$7,113.50 ",
"Malignancy, Female Reproductive System W MCC",754,MS-DRG,100,RC,,,inpatient,,,,,,"$4,801.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,801.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,495.06 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,331.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,168.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,413.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,168.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,413.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,331.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,801.22 ","$8,495.06 ",
"Malignancy, Female Reproductive System W CC",755,MS-DRG,100,RC,,,inpatient,,,,,,"$4,334.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,334.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,669.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,522.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,374.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,595.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,374.71 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,595.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,522.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,334.74 ","$7,669.69 ",
"Malignancy, Female Reproductive System W/O CC/MCC",756,MS-DRG,100,RC,,,inpatient,,,,,,"$2,672.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,672.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,728.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,637.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,546.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,683.20 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,546.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,683.20 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,637.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,672.53 ","$4,728.66 ",
"Infections, Female Reproductive System W MCC",757,MS-DRG,100,RC,,,inpatient,,,,,,"$3,729.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,729.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,599.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,472.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,345.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,536.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,345.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,536.17 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,472.71 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,729.96 ","$6,599.63 ",
"Infections, Female Reproductive System W CC",758,MS-DRG,100,RC,,,inpatient,,,,,,"$3,014.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,014.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,333.14 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,230.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,128.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,281.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,128.02 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,281.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,230.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,014.17 ","$5,333.14 ",
"Infections, Female Reproductive System W/O CC/MCC",759,MS-DRG,100,RC,,,inpatient,,,,,,"$2,293.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,293.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,058.05 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,980.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,901.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,019.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,901.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,019.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,980.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,293.52 ","$4,058.05 ",
Menstrual & Other Female Reproductive System Disorders W CC/MCC,760,MS-DRG,100,RC,,,inpatient,,,,,,"$2,751.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,751.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,868.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,775.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,681.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,822.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,681.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,822.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,775.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,751.78 ","$4,868.87 ",
Menstrual & Other Female Reproductive System Disorders W/O CC/MCC,761,MS-DRG,100,RC,,,inpatient,,,,,,"$2,143.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,143.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,792.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,719.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,646.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,755.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,646.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,755.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,719.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,143.26 ","$3,792.19 ",
Cesarean Section W CC/MCC,765,MS-DRG,100,RC,,,inpatient,,,,,,"$3,751.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,751.27 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,637.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,509.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,382.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,573.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,382.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,573.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,509.68 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,751.27 ","$6,637.32 ",
Cesarean Section W/O CC/MCC,766,MS-DRG,100,RC,,,inpatient,,,,,,"$3,056.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,056.78 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,408.53 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,304.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,200.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,356.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,200.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,356.53 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,304.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,056.78 ","$5,408.53 ",
Vaginal Delivery W Sterilization &/or D&C,767,MS-DRG,100,RC,,,inpatient,,,,,,"$3,288.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,288.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,819.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,707.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,595.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,763.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,595.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,763.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,707.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,288.90 ","$5,819.23 ",
Vaginal Delivery W O.R. Proc Except Steril &/or D&C,768,MS-DRG,100,RC,,,inpatient,,,,,,"$3,055.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,055.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,406.55 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,302.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,198.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,354.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,198.61 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,354.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,302.58 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,055.66 ","$5,406.55 ",
Postpartum & Post Abortion Diagnoses W O.R. Procedure,769,MS-DRG,100,RC,,,inpatient,,,,,,"$4,859.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,859.53 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,598.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,432.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,267.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,515.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,267.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,515.56 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,432.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,859.53 ","$8,598.23 ",
"Abortion W D&C, aspiration Curettage or Hysterotomy",770,MS-DRG,100,RC,,,inpatient,,,,,,"$2,421.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,421.73 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,284.90 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,202.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,120.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,243.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,120.09 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,243.70 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,202.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,421.73 ","$4,284.90 ",
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,100,RC,,,inpatient,,,,,,"$2,736.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,736.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,842.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,749.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,656.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,795.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,656.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,795.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,749.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,736.82 ","$4,842.42 ",
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,100,RC,,,inpatient,,,,,,"$2,395.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,395.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,237.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,156.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,074.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,197.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,074.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,197.19 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,156.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,395.19 ","$4,237.94 ",
Postpartum & Post Abortion Diagnoses W/O O.R. Procedure,776,MS-DRG,100,RC,,,inpatient,,,,,,"$2,424.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,424.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,289.53 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,207.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,124.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,248.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,124.54 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,248.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,207.04 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,424.34 ","$4,289.53 ",
Ectopic Pregnancy,777,MS-DRG,100,RC,,,inpatient,,,,,,"$3,281.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,281.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,806.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,695.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,583.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,750.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,583.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,750.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,695.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,281.80 ","$5,806.67 ",
Threatened Abortion,778,MS-DRG,100,RC,,,inpatient,,,,,,"$2,520.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,520.41 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,459.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,373.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,287.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,416.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,287.97 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,416.61 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,373.73 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,520.41 ","$4,459.49 ",
Abortion W/O D&C,779,MS-DRG,100,RC,,,inpatient,,,,,,"$2,007.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,007.20 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,551.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,483.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,414.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,517.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,414.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,517.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,483.16 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,007.20 ","$3,551.46 ",
False Labor,780,MS-DRG,100,RC,,,inpatient,,,,,,"$2,422.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,422.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,285.56 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,203.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,120.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,244.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,120.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,244.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,203.14 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,422.10 ","$4,285.56 ",
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,100,RC,,,inpatient,,,,,,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,213.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,946.52 ","$5,213.43 ",
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,100,RC,,,inpatient,,,,,,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,946.52 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,213.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,012.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,163.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,113.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,946.52 ","$5,213.43 ",
"Neonate, Birthwt >2499G, W Signif O.R. Proc, W/O Mult Major Prob",787,MS-DRG,100,RC,,,inpatient,,,,,,"$2,667.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,667.67 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,720.07 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,629.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,538.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,674.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,538.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,674.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,629.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,667.67 ","$4,720.07 ",
"Neonate, Birthwt >2499G, W Minor Abdom Procedure",788,MS-DRG,100,RC,,,inpatient,,,,,,"$2,898.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,898.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,128.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,029.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,930.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,078.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,930.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,078.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,029.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,898.30 ","$5,128.12 ",
"Neonate, Birthwt >2499G, W/O Signif O.R. Proc, W Mult Major Prob",789,MS-DRG,100,RC,,,inpatient,,,,,,"$7,476.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,476.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,228.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,973.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,719.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,101.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,719.57 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,101.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,973.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,476.37 ","$13,228.35 ",
"Neonate, Birthwt >2499G, W/O Signif O.R. Proc, W Major Prob",790,MS-DRG,100,RC,,,inpatient,,,,,,"$2,666.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,666.93 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,718.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,628.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,537.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,673.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,537.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,673.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,628.00 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,666.93 ","$4,718.74 ",
"Neonate, Birthwt >2499G, W/O Signif O.R. Proc, W Minor Prob",791,MS-DRG,100,RC,,,inpatient,,,,,,"$1,403.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,403.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,482.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,434.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,387.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,458.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,387.22 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,458.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,434.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,403.17 ","$2,482.71 ",
"Neonate, Birthwt >2499G, W/O Signif O.R. Proc, W Other Prob",792,MS-DRG,100,RC,,,inpatient,,,,,,"$1,058.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,058.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,872.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,836.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,800.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,854.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,800.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,854.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$1,836.28 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,058.17 ","$1,872.29 ",
Neonatal Aftercare for Weight Gain,793,MS-DRG,100,RC,,,inpatient,,,,,,"$6,534.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,534.44 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,561.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,339.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,117.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,450.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,117.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,450.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,339.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,534.44 ","$11,561.75 ",
"Neonatal Diagnosis, Age > 28 Days",794,MS-DRG,100,RC,,,inpatient,,,,,,"$15,979.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,979.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,273.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,729.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,186.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,001.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,186.00 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,001.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,729.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,979.51 ","$28,273.44 ",
Normal Newborn,795,MS-DRG,100,RC,,,inpatient,,,,,,$815.96 ,100,,,other,Amerigroup DRG using base rate 3737.81,$815.96 ,100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,443.73 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,415.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,388.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,429.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,388.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$1,429.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$1,415.97 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,$815.96 ,"$1,443.73 ",
"Multiple, Other And Unspecified Congenital Anomalies, W CC/MCC",796,MS-DRG,100,RC,,,inpatient,,,,,,"$3,935.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,935.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,964.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,830.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,696.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,897.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,696.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,897.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,830.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,935.91 ","$6,964.03 ",
"Multiple, Other And Unspecified Congenital Anomalies, W/O CC/MCC",797,MS-DRG,100,RC,,,inpatient,,,,,,"$3,935.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,935.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,964.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,830.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,696.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,897.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,696.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,897.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,830.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,935.91 ","$6,964.03 ",
Splenectomy Age >17 W MCC,799,MS-DRG,100,RC,,,inpatient,,,,,,"$10,712.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,712.94 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,955.00 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,590.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,225.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,772.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,225.96 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,772.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,590.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,712.94 ","$18,955.00 ",
Splenectomy Age >17 W CC,800,MS-DRG,100,RC,,,inpatient,,,,,,"$7,992.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,992.19 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,141.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,869.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,597.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,005.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,597.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,005.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,869.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,992.19 ","$14,141.02 ",
Splenectomy Age >17 W/O CC/MCC,801,MS-DRG,100,RC,,,inpatient,,,,,,"$5,252.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,252.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,293.31 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,114.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,935.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,203.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,935.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,203.95 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,114.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,252.37 ","$9,293.31 ",
Other O.R. Proc of the Blood & Blood forming Organs W MCC,802,MS-DRG,100,RC,,,inpatient,,,,,,"$10,336.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,336.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,289.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,937.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,585.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,113.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,585.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,113.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,937.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,336.54 ","$18,289.02 ",
Other O.R. Proc of the Blood & Blood forming Organs W CC,803,MS-DRG,100,RC,,,inpatient,,,,,,"$4,985.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,985.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,821.11 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,651.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,481.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,736.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,481.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,736.29 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,651.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,985.49 ","$8,821.11 ",
Other O.R. Proc of the Blood & Blood forming Organs W/O CC/MCC,804,MS-DRG,100,RC,,,inpatient,,,,,,"$4,102.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,102.99 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,259.66 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,120.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,980.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,189.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,980.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,189.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,120.05 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,102.99 ","$7,259.66 ",
Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W MCC,808,MS-DRG,100,RC,,,inpatient,,,,,,"$10,724.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,724.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,974.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,609.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,245.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,792.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,245.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,792.39 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,609.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,724.15 ","$18,974.84 ",
Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W CC,809,MS-DRG,100,RC,,,inpatient,,,,,,"$5,074.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,074.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,977.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,805.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,632.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,891.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,632.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,891.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,805.20 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,074.08 ","$8,977.85 ",
Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W/O CC/MCC,810,MS-DRG,100,RC,,,inpatient,,,,,,"$2,583.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,583.57 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,571.26 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,483.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,395.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,527.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,395.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,527.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,483.35 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,583.57 ","$4,571.26 ",
Red Blood Cell Disorders Age >17 W MCC,811,MS-DRG,100,RC,,,inpatient,,,,,,"$5,601.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,601.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,910.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,719.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,529.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,815.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,529.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,815.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,719.77 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,601.11 ","$9,910.35 ",
Red Blood Cell Disorders Age >17 W/O MCC,812,MS-DRG,100,RC,,,inpatient,,,,,,"$3,173.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,173.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,614.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,506.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,398.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,560.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,398.28 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,560.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,506.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,173.03 ","$5,614.21 ",
Coagulation Disorders,813,MS-DRG,100,RC,,,inpatient,,,,,,"$4,563.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,563.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,073.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,918.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,763.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,996.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,763.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,996.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,918.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,563.12 ","$8,073.78 ",
Reticuloendothelial & Immunity Disorders W MCC,814,MS-DRG,100,RC,,,inpatient,,,,,,"$4,203.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,203.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,437.56 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,294.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,151.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,366.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,151.50 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,366.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,294.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,203.54 ","$7,437.56 ",
Reticuloendothelial & Immunity Disorders W CC,815,MS-DRG,100,RC,,,inpatient,,,,,,"$3,296.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,296.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,833.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,720.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,608.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,777.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,608.77 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,777.03 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,720.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,296.75 ","$5,833.12 ",
Reticuloendothelial & Immunity Disorders W/O CC/MCC,816,MS-DRG,100,RC,,,inpatient,,,,,,"$2,167.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,167.18 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,834.52 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,760.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,687.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,797.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,687.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,797.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,760.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,167.18 ","$3,834.52 ",
Lymphoma & Leukemia W Major O.R. Procedure W MCC,820,MS-DRG,100,RC,,,inpatient,,,,,,"$17,623.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,623.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$31,181.41 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,581.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,982.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,881.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,982.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,881.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$30,581.76 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,623.03 ","$31,181.41 ",
Lymphoma & Leukemia W Major O.R. Procedure W CC,821,MS-DRG,100,RC,,,inpatient,,,,,,"$7,442.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,442.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,168.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,914.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,661.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,041.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,661.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,041.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,914.94 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,442.35 ","$13,168.17 ",
Lymphoma & Leukemia W Major O.R. Procedure W/O CC/MCC,822,MS-DRG,100,RC,,,inpatient,,,,,,"$4,214.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,214.75 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,457.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,313.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,170.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,385.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,170.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,385.69 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,313.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,214.75 ","$7,457.40 ",
Lymphoma & Non-Acute Leukemia W Other Proc W MCC,823,MS-DRG,100,RC,,,inpatient,,,,,,"$13,912.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,912.13 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,615.51 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,142.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,668.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,378.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,668.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,378.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$24,142.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,912.13 ","$24,615.51 ",
Lymphoma & Non-Acute Leukemia W Other Proc W CC,824,MS-DRG,100,RC,,,inpatient,,,,,,"$7,503.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,503.65 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,276.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,021.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,765.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,148.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,765.99 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,148.97 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,021.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,503.65 ","$13,276.63 ",
Lymphoma & Non-Acute Leukemia W Other Proc W/O CC/MCC,825,MS-DRG,100,RC,,,inpatient,,,,,,"$4,917.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,917.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,700.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,533.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,366.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,617.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,366.10 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,617.08 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,533.42 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,917.46 ","$8,700.74 ",
Myeloprolif Disord or Poorly Diff Neopl W Maj O.R. Proc W MCC,826,MS-DRG,100,RC,,,inpatient,,,,,,"$14,734.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,734.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,069.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,568.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,067.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,819.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,067.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,819.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,568.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,734.07 ","$26,069.82 ",
Myeloprolif Disord or Poorly Diff Neopl W Maj O.R. Proc W CC,827,MS-DRG,100,RC,,,inpatient,,,,,,"$6,559.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,559.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,606.72 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,383.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,160.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,495.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,160.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,495.12 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,383.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,559.86 ","$11,606.72 ",
Myeloprolif Disord or Poorly Diff Neopl W Maj O.R. Proc W/O CC/MCC,828,MS-DRG,100,RC,,,inpatient,,,,,,"$4,727.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,727.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,364.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,203.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,043.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,284.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,043.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,284.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,203.91 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,727.58 ","$8,364.78 ",
Myeloproliferative Disorders or Poorly Differentiated Neoplasms W Other Proc,829,MS-DRG,100,RC,,,inpatient,,,,,,"$8,612.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,612.66 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,238.86 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,945.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,652.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,092.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,652.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,092.34 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,945.81 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,612.66 ","$15,238.86 ",
Myeloproliferative Disorders or Poorly Differentiated Neoplasms W Other Proc,830,MS-DRG,100,RC,,,inpatient,,,,,,"$3,571.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,571.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,319.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,197.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,076.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,258.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,076.17 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,258.45 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,197.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,571.48 ","$6,319.21 ",
Acute Leukemia W/O Major O.R. Procedure Age >17 W MCC,834,MS-DRG,100,RC,,,inpatient,,,,,,"$30,811.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$30,811.14 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$54,515.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$53,467.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$52,419.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$53,991.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$52,419.11 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$53,991.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$53,467.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$30,811.14 ","$54,515.87 ",
Acute Leukemia W/O Major O.R. Procedure Age >17 W CC,835,MS-DRG,100,RC,,,inpatient,,,,,,"$8,842.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,842.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,646.26 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,345.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,044.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,495.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,044.48 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,495.81 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,345.37 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,842.91 ","$15,646.26 ",
Acute Leukemia W/O Major O.R. Procedure Age >17 W/O CC/MCC,836,MS-DRG,100,RC,,,inpatient,,,,,,"$3,580.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,580.07 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,334.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,212.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,090.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,273.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,090.79 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,273.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,212.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,580.07 ","$6,334.43 ",
Chemo W Acute Leukemia as Sdx or W High Dose Chemo Agent W MCC,837,MS-DRG,100,RC,,,inpatient,,,,,,"$17,482.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$17,482.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,933.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,338.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,743.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,635.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$29,743.65 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$30,635.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$30,338.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$17,482.86 ","$30,933.40 ",
Chemo W Acute Leukemia as Sdx W CC or High Dose Chemo Agent,838,MS-DRG,100,RC,,,inpatient,,,,,,"$5,523.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,523.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,773.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,585.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,397.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,679.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,397.55 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,679.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,585.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,523.74 ","$9,773.45 ",
Chemo W Acute Leukemia as Sdx W/O CC/MCC,839,MS-DRG,100,RC,,,inpatient,,,,,,"$3,754.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,754.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,642.62 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,514.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,387.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,578.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,387.13 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,578.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,514.87 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,754.26 ","$6,642.62 ",
Lymphoma & Non-Acute Leukemia W MCC,840,MS-DRG,100,RC,,,inpatient,,,,,,"$15,550.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$15,550.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,513.55 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,984.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,455.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,249.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,455.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,249.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$26,984.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$15,550.04 ","$27,513.55 ",
Lymphoma & Non-Acute Leukemia W CC,841,MS-DRG,100,RC,,,inpatient,,,,,,"$5,312.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,312.55 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,399.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,219.03 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,038.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,309.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,038.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,309.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,219.03 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,312.55 ","$9,399.79 ",
Lymphoma & Non-Acute Leukemia W/O CC/MCC,842,MS-DRG,100,RC,,,inpatient,,,,,,"$4,252.88 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,252.88 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,524.86 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,380.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,235.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,452.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,235.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,452.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,380.15 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,252.88 ","$7,524.86 ",
Other Myeloprolif Dis or Poorly Diff Neopl Diag W MCC,843,MS-DRG,100,RC,,,inpatient,,,,,,"$4,739.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,739.92 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,386.60 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,225.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,064.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,305.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,064.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,305.96 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,225.32 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,739.92 ","$8,386.60 ",
Other Myeloprolif Dis or Poorly Diff Neopl Diag W CC,844,MS-DRG,100,RC,,,inpatient,,,,,,"$3,204.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,204.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,670.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,561.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,452.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,615.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,452.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,615.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,561.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,204.80 ","$5,670.43 ",
Other Myeloprolif Dis or Poorly Diff Neopl Diag W/O CC/MCC,845,MS-DRG,100,RC,,,inpatient,,,,,,"$2,698.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,698.70 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,774.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,683.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,591.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,729.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,591.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,729.05 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,683.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,698.70 ","$4,774.96 ",
Chemotherapy W/O Acute Leukemia as Secondary Diagnosis W MCC,846,MS-DRG,100,RC,,,inpatient,,,,,,"$8,201.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,201.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,511.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,232.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,953.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,371.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,953.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,371.84 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,232.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,201.50 ","$14,511.38 ",
Chemotherapy W/O Acute Leukemia as Secondary Diagnosis W CC,847,MS-DRG,100,RC,,,inpatient,,,,,,"$4,607.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,607.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,152.48 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,995.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,838.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,074.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,838.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,074.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,995.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,607.60 ","$8,152.48 ",
Chemotherapy W/O Acute Leukemia as Secondary Diagnosis W/O CC/MCC,848,MS-DRG,100,RC,,,inpatient,,,,,,"$2,303.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,303.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,075.25 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,996.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,918.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,036.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,918.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,036.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,996.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,303.24 ","$4,075.25 ",
Radiotherapy,849,MS-DRG,100,RC,,,inpatient,,,,,,"$3,230.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,230.22 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,715.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,605.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,495.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,660.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,495.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,660.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,605.49 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,230.22 ","$5,715.40 ",
Infectious & Parasitic Diseases W O.R. Procedure W MCC,853,MS-DRG,100,RC,,,inpatient,,,,,,"$20,934.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,934.35 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,040.32 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,328.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,615.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,684.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,615.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,684.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$36,328.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,934.35 ","$37,040.32 ",
Infectious & Parasitic Diseases W O.R. Procedure W CC,854,MS-DRG,100,RC,,,inpatient,,,,,,"$8,657.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,657.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,318.89 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,024.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,729.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,171.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,729.70 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,171.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$15,024.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,657.89 ","$15,318.89 ",
Infectious & Parasitic Diseases W O.R. Procedure W/O CC/MCC,855,MS-DRG,100,RC,,,inpatient,,,,,,"$5,462.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,462.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,664.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,478.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,292.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,571.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,292.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,571.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,478.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,462.06 ","$9,664.33 ",
Postoperative or Post-Traumatic Infections W O.R. Proc W MCC,856,MS-DRG,100,RC,,,inpatient,,,,,,"$14,995.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,995.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,532.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,022.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,512.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,277.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,512.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,277.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$26,022.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,995.72 ","$26,532.76 ",
Postoperative or Post-Traumatic Infections W O.R. Proc W CC,857,MS-DRG,100,RC,,,inpatient,,,,,,"$6,672.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,672.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,806.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,579.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,352.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,692.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,352.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,692.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,579.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,672.74 ","$11,806.45 ",
Postoperative or Post-Traumatic Infections W O.R. Proc W/O CC/MCC,858,MS-DRG,100,RC,,,inpatient,,,,,,"$5,846.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,846.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,344.20 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,145.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,946.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,244.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,946.35 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,244.74 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,145.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,846.31 ","$10,344.20 ",
Postoperative & Post-Traumatic Infections W MCC,862,MS-DRG,100,RC,,,inpatient,,,,,,"$5,870.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,870.60 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,387.19 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,187.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,987.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,287.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,987.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,287.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,187.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,870.60 ","$10,387.19 ",
Postoperative & Post-Traumatic Infections W/O MCC,863,MS-DRG,100,RC,,,inpatient,,,,,,"$3,220.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,220.87 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,698.87 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,589.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,479.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,644.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,479.68 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,644.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,589.27 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,220.87 ","$5,698.87 ",
Fever Age > 17,864,MS-DRG,100,RC,,,inpatient,,,,,,"$3,019.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,019.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,341.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,239.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,136.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,290.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,136.29 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,290.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,239.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,019.03 ","$5,341.74 ",
Viral Illness Age >17 W MCC,865,MS-DRG,100,RC,,,inpatient,,,,,,"$2,932.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,932.69 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,188.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,089.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,989.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,139.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,989.39 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,139.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,089.18 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,932.69 ","$5,188.96 ",
Viral Illness Age >17 W/O MCC,866,MS-DRG,100,RC,,,inpatient,,,,,,"$2,687.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,687.49 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,755.12 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,663.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,572.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,709.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,572.23 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,709.40 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,663.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,687.49 ","$4,755.12 ",
Other Infectious & Parasitic Diseases Diagnoses W MCC,867,MS-DRG,100,RC,,,inpatient,,,,,,"$6,618.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,618.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,709.89 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,484.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,259.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,597.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,259.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,597.30 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,484.70 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,618.17 ","$11,709.89 ",
Other Infectious & Parasitic Diseases Diagnoses W CC,868,MS-DRG,100,RC,,,inpatient,,,,,,"$2,899.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,899.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,130.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,032.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,933.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,081.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,933.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,081.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,032.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,899.79 ","$5,130.77 ",
Other Infectious & Parasitic Diseases Diagnoses W/O CC/MCC,869,MS-DRG,100,RC,,,inpatient,,,,,,"$2,899.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,899.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,130.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,032.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,933.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,081.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,933.43 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,081.43 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,032.10 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,899.79 ","$5,130.77 ",
Septicemia or Severe Sepsis W Mv >96 Hours Age >17,870,MS-DRG,100,RC,,,inpatient,,,,,,"$22,345.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$22,345.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,536.92 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,776.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,016.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,156.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,016.27 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,156.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$38,776.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$22,345.38 ","$39,536.92 ",
Septicemia or Severe Sepsis W/O Mv >96 Hours Age >17 W MCC,871,MS-DRG,100,RC,,,inpatient,,,,,,"$6,922.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,922.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,248.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,012.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,777.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,130.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,777.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,130.46 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,012.69 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,922.42 ","$12,248.23 ",
Septicemia or Severe Sepsis W/O Mv >96 Hours Age >17 W/O MCC,872,MS-DRG,100,RC,,,inpatient,,,,,,"$3,720.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,720.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,583.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,456.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,329.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,519.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,329.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,519.79 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,456.50 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,720.62 ","$6,583.09 ",
O.R. Procedure W Principal Diagnoses of Mental Illness,876,MS-DRG,100,RC,,,inpatient,,,,,,"$7,322.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$7,322.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,955.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,706.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,456.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,830.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,456.94 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,830.65 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$12,706.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$7,322.00 ","$12,955.22 ",
Acute Adjustment Reaction & Psychosocial Dysfunction,880,MS-DRG,100,RC,,,inpatient,,,,,,"$2,312.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,312.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,092.44 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,013.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,935.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,053.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,935.04 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,053.09 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,013.74 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,312.96 ","$4,092.44 ",
Depressive Neuroses,881,MS-DRG,100,RC,,,inpatient,,,,,,"$1,995.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,995.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,530.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,462.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,394.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,496.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,394.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,496.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,462.40 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,995.24 ","$3,530.29 ",
Neuroses Except Depressive,882,MS-DRG,100,RC,,,inpatient,,,,,,"$2,055.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,055.42 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,636.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,566.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,496.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,601.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,496.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,601.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,566.83 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,055.42 ","$3,636.77 ",
Disorders of Personality & Impulse Control,883,MS-DRG,100,RC,,,inpatient,,,,,,"$2,947.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,947.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,214.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,114.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,014.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,164.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,014.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,164.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,114.47 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,947.26 ","$5,214.76 ",
organic Disturbances & Intellectual Disability,884,MS-DRG,100,RC,,,inpatient,,,,,,"$4,189.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,189.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,412.43 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,269.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,127.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,341.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,127.34 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,341.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,269.88 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,189.34 ","$7,412.43 ",
Psychoses,885,MS-DRG,100,RC,,,inpatient,,,,,,"$2,699.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,699.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,776.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,685.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,593.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,731.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,593.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,731.01 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,685.08 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,699.82 ","$4,776.94 ",
Behavioral & Developmental Disorders,886,MS-DRG,100,RC,,,inpatient,,,,,,"$2,136.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,136.91 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,780.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,708.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,635.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,744.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,635.53 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,744.59 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,708.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,136.91 ","$3,780.95 ",
Other Mental Disorder Diagnoses,887,MS-DRG,100,RC,,,inpatient,,,,,,"$2,224.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,224.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,935.70 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,860.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,784.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,897.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,784.33 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,897.86 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,860.02 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,224.37 ","$3,935.70 ",
"Alcohol/Drug Abuse or Dependence, Left Ama",894,MS-DRG,100,RC,,,inpatient,,,,,,"$2,158.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,158.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,819.97 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,746.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,673.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,783.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,673.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,783.24 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,746.51 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,158.96 ","$3,819.97 ",
Alcohol/Drug Abuse or Dependence W Rehabilitation therapy,895,MS-DRG,100,RC,,,inpatient,,,,,,"$1,652.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,652.11 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,923.17 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,866.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,810.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,895.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,810.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$2,895.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$2,866.96 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,652.11 ","$2,923.17 ",
Alcohol/Drug Abuse or Dependence W/O Rehabilitation therapy W MCC,896,MS-DRG,100,RC,,,inpatient,,,,,,"$5,225.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,225.08 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,245.03 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,067.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,889.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,156.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,889.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,156.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,067.24 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,225.08 ","$9,245.03 ",
Alcohol/Drug Abuse or Dependence W/O Rehabilitation therapy Age >21 W/O MCC,898,MS-DRG,100,RC,,,inpatient,,,,,,"$2,681.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,681.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,744.54 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,653.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,562.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,698.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,562.05 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,698.92 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,653.30 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,681.50 ","$4,744.54 ",
Alcohol/Drug Abuse or Dependence W/O Rehabilitation therapy Age <=21 W/O MCC,899,MS-DRG,100,RC,,,inpatient,,,,,,"$1,874.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,874.89 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,317.34 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,253.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,189.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,285.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,189.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,285.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,253.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,874.89 ","$3,317.34 ",
Wound Debridements for Injuries W MCC,901,MS-DRG,100,RC,,,inpatient,,,,,,"$11,483.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$11,483.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,318.04 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,927.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,536.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,122.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,536.58 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,122.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$19,927.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$11,483.30 ","$20,318.04 ",
Wound Debridements for Injuries W CC,902,MS-DRG,100,RC,,,inpatient,,,,,,"$5,155.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,155.56 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,122.02 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,946.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,771.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,034.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,771.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,034.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,946.60 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,155.56 ","$9,122.02 ",
Wound Debridements for Injuries W/O CC/MCC,903,MS-DRG,100,RC,,,inpatient,,,,,,"$3,741.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,741.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,619.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,492.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,364.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,555.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,364.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,555.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,492.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,741.17 ","$6,619.47 ",
Skin Grafts for Injuries W CC/MCC,904,MS-DRG,100,RC,,,inpatient,,,,,,"$9,843.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,843.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,417.36 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,082.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,747.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,249.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,747.46 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,249.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,082.41 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,843.90 ","$17,417.36 ",
Skin Grafts for Injuries W/O CC/MCC,905,MS-DRG,100,RC,,,inpatient,,,,,,"$5,171.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,171.26 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,149.80 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,973.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,797.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,061.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,797.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,061.82 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,973.84 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,171.26 ","$9,149.80 ",
Hand Procedures for Injuries,906,MS-DRG,100,RC,,,inpatient,,,,,,"$3,933.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,933.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,959.40 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,825.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,691.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,892.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,691.73 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,892.49 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,825.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,933.30 ","$6,959.40 ",
Other O.R. Procedures for Injuries W MCC,907,MS-DRG,100,RC,,,inpatient,,,,,,"$16,261.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,261.72 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,772.76 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,219.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,666.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,496.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,666.12 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,496.10 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$28,219.44 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,261.72 ","$28,772.76 ",
Other O.R. Procedures for Injuries W CC,908,MS-DRG,100,RC,,,inpatient,,,,,,"$6,547.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,547.15 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,584.23 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,361.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,138.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,472.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,138.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,472.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,361.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,547.15 ","$11,584.23 ",
Other O.R. Procedures for Injuries W/O CC/MCC,909,MS-DRG,100,RC,,,inpatient,,,,,,"$4,583.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,583.30 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,109.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,953.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,797.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,031.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,797.59 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,031.52 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,953.54 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,583.30 ","$8,109.49 ",
Traumatic Injury Age >17 W MCC,913,MS-DRG,100,RC,,,inpatient,,,,,,"$4,239.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,239.80 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,501.71 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,357.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,213.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,429.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,213.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,429.58 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,357.45 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,239.80 ","$7,501.71 ",
Traumatic Injury Age >17 W/O MCC,914,MS-DRG,100,RC,,,inpatient,,,,,,"$2,581.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,581.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,567.29 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,479.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,391.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,523.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,391.63 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,523.38 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,479.46 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,581.33 ","$4,567.29 ",
Allergic Reactions Age >17 W MCC,915,MS-DRG,100,RC,,,inpatient,,,,,,"$5,980.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,980.50 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,581.63 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,378.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,174.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,479.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,174.64 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,479.88 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$10,378.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,980.50 ","$10,581.63 ",
Allergic Reactions Age >17 W/O MCC,916,MS-DRG,100,RC,,,inpatient,,,,,,"$2,312.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,312.58 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,091.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,013.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,934.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,052.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,934.41 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,052.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,013.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,312.58 ","$4,091.78 ",
Poisoning & Toxic Effects of Drugs Age >17 W MCC,917,MS-DRG,100,RC,,,inpatient,,,,,,"$4,717.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,717.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,346.26 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,185.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,025.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,266.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,025.25 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,266.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,185.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,717.12 ","$8,346.26 ",
Poisoning & Toxic Effects of Drugs Age >17 W/O MCC,918,MS-DRG,100,RC,,,inpatient,,,,,,"$2,459.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,459.48 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,351.69 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,268.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,184.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,309.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,184.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,309.85 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,268.01 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,459.48 ","$4,351.69 ",
Complications of Treatment W MCC,919,MS-DRG,100,RC,,,inpatient,,,,,,"$4,447.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,447.62 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,869.42 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,718.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,566.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,793.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,566.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,793.76 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,718.09 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,447.62 ","$7,869.42 ",
Complications of Treatment W CC,920,MS-DRG,100,RC,,,inpatient,,,,,,"$4,104.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,104.86 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,262.96 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,123.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,983.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,193.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,983.62 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,193.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,123.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,104.86 ","$7,262.96 ",
Complications of Treatment W/O CC/MCC,921,MS-DRG,100,RC,,,inpatient,,,,,,"$2,831.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,831.02 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,009.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,912.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,816.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,960.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,816.42 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,960.91 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,912.75 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,831.02 ","$5,009.08 ",
"Other Injury, Poisoning & Toxic Effect Diag W MCC",922,MS-DRG,100,RC,,,inpatient,,,,,,"$5,009.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,009.04 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,862.77 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,692.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,521.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,777.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,521.90 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,777.55 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,692.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,009.04 ","$8,862.77 ",
"Other Injury, Poisoning & Toxic Effect Diag W/O MCC",923,MS-DRG,100,RC,,,inpatient,,,,,,"$2,940.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,940.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,202.85 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,102.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,002.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,152.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,002.74 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,152.83 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,102.80 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,940.54 ","$5,202.85 ",
Extensive Burns or Full Thickness Burns W Mv >96 Hrs W Skin Graft,927,MS-DRG,100,RC,,,inpatient,,,,,,"$50,683.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$50,683.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$89,677.95 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$87,953.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$86,228.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,815.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$86,228.80 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$88,815.67 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$87,953.38 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$50,683.96 ","$89,677.95 ",
Full Thickness Burn W Skin Graft or Inhal Inj W CC/MCC,928,MS-DRG,100,RC,,,inpatient,,,,,,"$8,360.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,360.36 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,792.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,507.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,223.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,650.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,223.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,650.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,507.98 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,360.36 ","$14,792.45 ",
Full Thickness Burn W Skin Graft or Inhal Inj W/O CC/MCC,929,MS-DRG,100,RC,,,inpatient,,,,,,"$3,997.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,997.96 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,073.82 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,937.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,801.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,005.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,801.75 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,005.80 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,937.78 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,997.96 ","$7,073.82 ",
Extensive Burns or Full Thickness Burns W Mv >96 Hrs W/O Skin Graft,933,MS-DRG,100,RC,,,inpatient,,,,,,"$13,698.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,698.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,237.21 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,771.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,305.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,004.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,305.01 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$24,004.16 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,771.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,698.33 ","$24,237.21 ",
Full Thickness Burn W/O Skin Grft or Inhal Inj,934,MS-DRG,100,RC,,,inpatient,,,,,,"$3,593.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,593.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,358.90 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,236.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,114.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,297.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,114.32 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,297.75 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,236.61 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,593.90 ","$6,358.90 ",
Non-Extensive Burns,935,MS-DRG,100,RC,,,inpatient,,,,,,"$3,231.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,231.34 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,717.38 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,607.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,497.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,662.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,497.49 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,662.41 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,607.43 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,231.34 ","$5,717.38 ",
O.R. Proc W Diagnoses of Other Contact W Health Services W MCC,939,MS-DRG,100,RC,,,inpatient,,,,,,"$9,929.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$9,929.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,568.14 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,230.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,892.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,399.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$16,892.45 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,399.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$17,230.29 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$9,929.12 ","$17,568.14 ",
O.R. Proc W Diagnoses of Other Contact W Health Services W CC,940,MS-DRG,100,RC,,,inpatient,,,,,,"$6,558.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,558.74 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,604.74 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,381.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,158.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,493.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,158.40 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,493.15 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,381.57 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,558.74 ","$11,604.74 ",
O.R. Proc W Diagnoses of Other Contact W Health Services W/O CC/MCC,941,MS-DRG,100,RC,,,inpatient,,,,,,"$4,960.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,960.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,777.46 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,608.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,439.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,693.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,439.86 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,693.06 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$8,608.66 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,960.82 ","$8,777.46 ",
Rehabilitation W CC/MCC,945,MS-DRG,100,RC,,,inpatient,,,,,,"$13,283.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,283.06 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,502.45 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,050.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,598.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,276.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,598.51 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,276.47 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$23,050.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,283.06 ","$23,502.45 ",
Rehabilitation W/O CC/MCC,946,MS-DRG,100,RC,,,inpatient,,,,,,"$3,023.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,023.51 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,349.67 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,246.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,143.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,298.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,143.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,298.23 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,246.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,023.51 ","$5,349.67 ",
Signs & Symptoms W MCC,947,MS-DRG,100,RC,,,inpatient,,,,,,"$5,710.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,710.25 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,103.47 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,909.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,714.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,006.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,714.87 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$10,006.32 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,909.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,710.25 ","$10,103.47 ",
Signs & Symptoms W/O MCC,948,MS-DRG,100,RC,,,inpatient,,,,,,"$3,075.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,075.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,440.94 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,336.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,231.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,388.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,231.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,388.62 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,336.31 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,075.10 ","$5,440.94 ",
Aftercare W CC/MCC,949,MS-DRG,100,RC,,,inpatient,,,,,,"$8,230.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,230.28 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,562.30 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,282.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,002.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,422.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,002.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,422.28 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,282.26 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,230.28 ","$14,562.30 ",
Aftercare W/O CC/MCC,950,MS-DRG,100,RC,,,inpatient,,,,,,"$2,874.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$2,874.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,085.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,987.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,890.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,036.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$4,890.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,036.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$4,987.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$2,874.38 ","$5,085.79 ",
Other Factors Influencing Health Status,951,MS-DRG,100,RC,,,inpatient,,,,,,"$1,907.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$1,907.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,374.22 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,309.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,244.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,341.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,244.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$3,341.77 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$3,309.33 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$1,907.03 ","$3,374.22 ",
Craniotomy for Multiple Significant Trauma,955,MS-DRG,100,RC,,,inpatient,,,,,,"$22,223.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$22,223.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$39,321.98 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,565.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,809.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,943.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$37,809.60 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$38,943.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$38,565.79 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$22,223.90 ","$39,321.98 ",
"Limb Reattachment, Hip & Femur Proc for Multiple Significant Trauma",956,MS-DRG,100,RC,,,inpatient,,,,,,"$20,880.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$20,880.90 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,945.75 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,235.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,524.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,590.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$35,524.76 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$36,590.50 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$36,235.25 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$20,880.90 ","$36,945.75 ",
Other O.R. Procedures for Multiple Significant Trauma W MCC,957,MS-DRG,100,RC,,,inpatient,,,,,,"$31,661.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$31,661.12 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$56,019.79 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$54,942.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$53,865.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$55,481.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$53,865.18 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$55,481.14 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$54,942.48 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$31,661.12 ","$56,019.79 ",
Other O.R. Procedures for Multiple Significant Trauma W CC,958,MS-DRG,100,RC,,,inpatient,,,,,,"$13,045.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$13,045.33 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$23,081.83 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,637.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,194.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,859.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,194.07 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$22,859.89 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$22,637.95 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$13,045.33 ","$23,081.83 ",
Other O.R. Procedures for Multiple Significant Trauma W/O CC/MCC,959,MS-DRG,100,RC,,,inpatient,,,,,,"$8,035.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,035.17 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,217.08 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,943.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,670.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,080.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$13,670.26 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,080.37 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$13,943.67 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,035.17 ","$14,217.08 ",
Other Multiple Significant Trauma W MCC,963,MS-DRG,100,RC,,,inpatient,,,,,,"$12,149.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$12,149.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,495.91 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,082.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,669.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,289.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$20,669.15 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$21,289.22 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$21,082.53 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$12,149.00 ","$21,495.91 ",
Other Multiple Significant Trauma W CC,964,MS-DRG,100,RC,,,inpatient,,,,,,"$6,804.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,804.31 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$12,039.24 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,807.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,576.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,923.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,576.20 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,923.48 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,807.72 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,804.31 ","$12,039.24 ",
Other Multiple Significant Trauma W/O CC/MCC,965,MS-DRG,100,RC,,,inpatient,,,,,,"$3,378.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,378.98 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,978.62 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,863.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,748.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,921.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,748.67 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,921.13 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,863.65 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,378.98 ","$5,978.62 ",
Hiv W Extensive O.R. Procedure W MCC,969,MS-DRG,100,RC,,,inpatient,,,,,,"$16,084.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$16,084.54 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,459.28 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,911.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,364.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,185.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$27,364.69 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$28,185.64 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$27,911.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$16,084.54 ","$28,459.28 ",
Hiv W Extensive O.R. Procedure W/O MCC,970,MS-DRG,100,RC,,,inpatient,,,,,,"$10,811.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,811.24 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$19,128.93 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,761.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,393.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,945.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,393.21 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,945.00 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,761.07 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,811.24 ","$19,128.93 ",
Hiv W Major Related Condition W MCC,974,MS-DRG,100,RC,,,inpatient,,,,,,"$10,541.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$10,541.00 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,650.78 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,292.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,933.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,471.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$17,933.44 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$18,471.44 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$18,292.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$10,541.00 ","$18,650.78 ",
Hiv W Major Related Condition W CC,975,MS-DRG,100,RC,,,inpatient,,,,,,"$4,452.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,452.85 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,878.68 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,727.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,575.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,802.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,575.66 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,802.93 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,727.17 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,452.85 ","$7,878.68 ",
Hiv W Major Related Condition W/O CC/MCC,976,MS-DRG,100,RC,,,inpatient,,,,,,"$3,275.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,275.82 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,796.09 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,684.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,573.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,740.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,573.16 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$5,740.35 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$5,684.62 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,275.82 ","$5,796.09 ",
Hiv W or W/O Other Related Condition,977,MS-DRG,100,RC,,,inpatient,,,,,,"$4,535.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$4,535.46 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,024.84 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,870.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,716.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,947.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,716.19 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$7,947.68 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$7,870.52 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$4,535.46 ","$8,024.84 ",
Extensive O.R. Procedure Unrelated To Principal Diagnosis W MCC,981,MS-DRG,100,RC,,,inpatient,,,,,,"$18,963.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$18,963.03 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,552.35 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,907.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,261.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,229.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$32,261.88 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$33,229.73 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$32,907.11 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$18,963.03 ","$33,552.35 ",
Extensive O.R. Procedure Unrelated To Principal Diagnosis W CC,982,MS-DRG,100,RC,,,inpatient,,,,,,"$8,592.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$8,592.10 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,202.49 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,910.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,617.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,056.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$14,617.78 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$15,056.31 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$14,910.13 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$8,592.10 ","$15,202.49 ",
Extensive O.R. Procedure Unrelated To Principal Diagnosis W/O CC/MCC,983,MS-DRG,100,RC,,,inpatient,,,,,,"$5,212.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$5,212.38 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,222.55 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,045.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,867.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,133.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$8,867.83 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$9,133.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$9,045.19 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$5,212.38 ","$9,222.55 ",
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W MCC,987,MS-DRG,100,RC,,,inpatient,,,,,,"$14,885.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$14,885.83 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,338.33 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,831.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,325.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,085.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$25,325.31 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$26,085.07 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$25,831.82 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$14,885.83 ","$26,338.33 ",
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W CC,988,MS-DRG,100,RC,,,inpatient,,,,,,"$6,503.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$6,503.79 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,507.52 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,286.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,064.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,396.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,064.92 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$11,396.87 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$11,286.22 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$6,503.79 ","$11,507.52 ",
Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W/O CC/MCC,989,MS-DRG,100,RC,,,inpatient,,,,,,"$3,641.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,"$3,641.37 ",100,,,other,Amerigroup DRG using base rate 3737.81,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,442.89 ",104,,,other,104% Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,318.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,195.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,380.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,195.08 ",100,,,other,100% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,"$6,380.94 ",103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,"$6,318.99 ",102,,,other,102% GA Medicaid DRG using base rate 6359.15,"$3,641.37 ","$6,442.89 ",
Principal Diagnosis Invalid as Discharge Diagnosis,998,MS-DRG,100,RC,,,inpatient,,,,,,,100,,,other,Not seperately reimbursable,,100,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimburable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,
Ungroupable,999,MS-DRG,100,RC,,,inpatient,,,,,,,100,,,other,Not seperately reimbursable,,100,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimburable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,,,,other,Not seperately reimbursable for DRG,,103,,,other,103% GA Medicaid DRG using base rate 6359.15,,,,,other,Not seperately reimbursable for DRG,,102,,,other,102% GA Medicaid DRG using base rate 6359.15,,,